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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202301
Report Date: 04/21/2022
Date Signed: 04/21/2022 04:41:47 PM


Document Has Been Signed on 04/21/2022 04:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:PALM VILLAS, CAMPBELLFACILITY NUMBER:
435202301
ADMINISTRATOR:SNEPER, GARRYFACILITY TYPE:
740
ADDRESS:3333 SOUTH BASCOM AVENUETELEPHONE:
(408) 559-8301
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:48CENSUS: DATE:
04/21/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Brisa RomeroTIME COMPLETED:
04:45 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced case management visit regarding the facility's current probationary license. LPA met with facility administrators Brisa Romero (Admin 1) and Gary Sneper (Admin 2).

LPA toured the facility with Admin 1. During tour of the facility, LPA observed the facility to be operating within regulation, including compliance with personal rights and allowable health conditions. LPA observed the facility's probationary license posted both on the bulletin board outside of the Administrators office, as well as framed in the receptionist's office. LPA confirmed maintenance of home health agreements.

Admin identified licensed vocational nurse Melissa Bray (LVN) the facility's Infection Prevention (IP) specialist. LPA observed RN working at the facility during the inspection. In interview with LVN, LVN stated that they had been working at the facility since February. LPA reviewed LVN's IP training certificates. Records indicated that between the days of 02/11/2022 and 02/15/2022, RN completed 17 courses related to infection prevention. LPA confirmed completion of staff training on infection prevention.

During the inspection, LPA requested administrator training documentation. During records review, LPA observed that from the dates of 02/03/2022 to 03/15/2022, Admin 2 completed 42 hours of training.

Facility request to lift probationary period is currently under review

No deficiencies cited during today's visit. This report was reviewed with facility administrator Brisa Romero and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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