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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202301
Report Date: 12/05/2023
Date Signed: 12/05/2023 01:36:28 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: 42DATE:
12/05/2023
UNANNOUNCEDTIME BEGAN:
11:08 AM
MET WITH:Myra BelzaTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not monitor residents interaction with each other.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/5/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegation. LPA met with Office Manager Myra Belza. LPA explained the purpose of the visit.

Regarding the allegation of Staff did not monitor residents’ interaction with each other, RP stated that On 10/20/2021 at 10 pm, RP saw three staff watching football game on TV while one resident was in the dining room (no staff supervising), and another resident down a hall. RP wondered if staff were too busy to ensure safety of residents.

Based on interviews, both Resident Services Director (RSD) & Office Manager (OM) mentioned that around 10 pm is the change in shift between staff. The staff that were sitting and watching were already off and has turned over to the night shift.

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.

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: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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