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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202301
Report Date: 11/16/2022
Date Signed: 11/16/2022 03:05:40 PM


Document Has Been Signed on 11/16/2022 03:05 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: 44DATE:
11/16/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:BlythTIME COMPLETED:
03:07 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 Resident Services Director Blyth Obien (RSD).

LPA toured the facility with RSD. 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 and in the waiting room outside of administrative offices. The facility does not currently have any residents that are utilizing home health agreements. The only resident that had been under home health previously is now under hospice services instead

RSD is still the facility infection prevention specialist. IP qualifications have been previously reviewed by LPA.

No additional administrator training documentation has been generated since case management inspection on 07/12/2022. Admin has already completed all necessary course work.

No deficiencies cited during today's visit. This report was reviewed with Resident Services Director Blyth Obien 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: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
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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