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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202301
Report Date: 08/04/2022
Date Signed: 08/04/2022 03:00:28 PM


Document Has Been Signed on 08/04/2022 03:00 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
CENTRAL COAST CR/RES, 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: 41DATE:
08/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:NoraTIME COMPLETED:
03:05 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 08/04/2022 at 1:05pm. LPA met with Palm Villas Administrator Nora Saavera (S1). Administrator Gary Sneper (Admin) was currently on vacation and was unable to attend the inspection. LPA was informed that Admin would be on vacation during inspection that took place on 07/12/2022. During 07/12/2022 inspection Admin stated that S1 would be able to sign reports in his stead.

LPA toured the facility, including courtyard, front offices, medication room, dining hall, kitchen, TV room, all facility bathrooms, 10 resident rooms, kitchen, laundry room, front offices, storage room, and break room.

All staff members observed to be wearing masks. Hand washing, cough sneeze etiquette, and social distancing signs observed in all facility common areas. Facility observed to have designated entry point. Staff took LPA's temperature and screened for symptoms.

LPA observed all facility bathrooms to have adequate supply of paper supplies and soap. LPA observed that bathroom garbage cans have lids. When inspecting facility, LPA noted that facility had over 30-days worth of N95s, gowns, gloves, face shields, and booties. Kitchen observed to have adequate supply of perishable and nonperishable food. Water temperature tested in facility bathroom and observed to be 113.5*F. Facility temperature noted at 77*F. Facility fire extinguishers were noted to have been inspected in May of 2022.

No deficiencies cited during this inspection. This report reviewed with Palm Villas Administrator Nora Saavera and a copy of the signed report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
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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