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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202301
Report Date: 11/21/2023
Date Signed: 12/05/2023 01:37:56 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/09/2021 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20211109171759
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: 46DATE:
11/21/2023
UNANNOUNCEDTIME BEGAN:
11:34 AM
MET WITH:Blyth Obien & Myra BelzaTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Illegal Eviction
Facility is restricting visitation
Resident sustained unexplained injuries
Staff did not report an incident to resident's representative
INVESTIGATION FINDINGS:
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On 11/21/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegations. LPA met with Blyth Obien, Resident Services Director Myra Belza, Office Manager. LPA explained the purpose of the visit.

Regarding the allegation of illegal eviction, the reporting party (RP) stated that Administrator (S1) gave the resident (R1) a 30-day notice.

Based on interview with S1 and co-Administrator (S2), while there was a 30-day notice provided by the facility, R1 wasn’t evicted. Responsible parties, S1 & S2 reached an agreement that the resident will just be transferred since the facility is not able to cater to R1s higher level of care. Based on record reviews, it was stated in the 30-day notice the different incidents that have occurred and violated the facility’s house rules. Additionally, it was also noted that there is a need that wasn’t previously identified in the pre-appraisal that was conducted. It was indicated in the LIC 603 (Pre-Appraisal Form) that R1 doesn’t have any aggressive behaviors as reported by POA.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 26-AS-20211109171759
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: PALM VILLAS, CAMPBELL
FACILITY NUMBER: 435202301
VISIT DATE: 11/21/2023
NARRATIVE
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Regarding the allegation of facility restricting visitation, RP stated that visits were only 30 mins.

Based on interviews, S1 stated that RP is allowed to visit every day. No visitor has been denied visitation in the facility. They have scheduled visitation during this time. Even if visitors don’t have a schedule around this time, the facility still lets them in. Family visits are always accommodated. Depending also on the residents, the facility requests that they delay visitation for up to a week to allow for assimilation. It is never mandatory; it is only a recommendation.

LPA reviewed visitation logs and it showed that RP was able to sign in and temperature was checked upon entering the facility as well as other visitors visiting other residents. Based on records review, the facility was also following some COVID-19 protocols during this time. Visitation is allowed but Screening protocol is followed, scheduled visitation, well-fitting face mask are always required upon entry and within the facility. Limit the number of visitors on the facility premises at any one time to avoid having large groups congregate. Facility encourages short indoor visits and longer outdoor visits.

Regarding the allegations resident’s sustained unexplained injuries and staff not reporting an incident to resident's representative. RP said the staff never reported a skin laceration to RP, RP stated that On 10/1/2021 staff reported to RP that R1 had a lemon size bruise on the outer arm.

Based on record reviews, this incident happened around 9/27/21 where staff found a skin discoloration on R1’s right arm. This skin discoloration was observed by staff during routine checks done in the facility. There were no prior incidents that happened before this, so it is hard to determine how R1 sustained this skin discoloration. On the progress reports for R1, its was stated there that incidents were all reported to physician and responsible parties. These incidents were also reported to Licensing.

Therefore, based on the interviews conducted, files reviewed, and information collected, the allegations mentioned are UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Report is reviewed and a copy is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2