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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202301
Report Date: 05/05/2023
Date Signed: 05/05/2023 12:06:02 PM


Document Has Been Signed on 05/05/2023 12:06 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: 40DATE:
05/05/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Garry SneperTIME COMPLETED:
12:08 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) and Administrator Garry Sneper (Admin).

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 currently has one resident utilizing home health services. LPA reviewed the resident's home health agreement, and confirmed via visitation reports that home health had been providing service as stipulated in the agreement.

RSD is still the facility infection prevention specialist. LPA reviewed RSD's IP certifications and verified that RSD's training records are up to date and complete.

No additional administrator training documentation has been generated since case management inspection on 07/12/2022. Admin has already completed all necessary course work. In review of administrator application packet, LPA confirmed that Admin submitted administrator renewal application packet on 07/05/2022.

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: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023
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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