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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202301
Report Date: 10/26/2020
Date Signed: 10/27/2020 08:21:23 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 22DATE:
10/26/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Brisa Romero, Michael Sneper, Garry SneperTIME COMPLETED:
04:45 PM
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On 10/26/2020 Licensing Program Analyst Ryker Heberle (LPA), Licensing Program Manager Sarah Yip (LPM), Regional Manager Vivien Helbling (RM), Program Clinical Consultant Helen Shi (PCC), Acting Assistant Program Administrator Krystal Moore (APA), and Santa Clara County Public Health Staff Members Jo Odias and Linda, conducted a status conference meeting via phone with the facility. Licensing met with Administrators Michael Sneper and Gary Sneper (Admins), as well as Executive Director Brisa Romero (ED). Facility currently has a census of 22 residents with 20 COVID positive cases.

During the tele-visit, licensing and Santa Clara County Public Health made the following recommendations to the facility:

1. Mitigation plan is due to CCL by 10/27/2020 by close of business day for further review by SCCPH

2. Update staff schedule to include medical director and Veronica Miranda by close of business day on 10/26/2020

3. Submit Infection Prevention Specialist hiring ad, as well as all the steps completed by the facility to hire Infection Prevention Specialist by close of business day 10/26/2020

4. Submit mass testing documentation for Palm Villas - Redwood City, including documentation of ongoing mass testing and when mass testing began.

Report continued on 809-C
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2020
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: PALM VILLAS, CAMPBELL
FACILITY NUMBER: 435202301
VISIT DATE: 10/26/2020
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At 2:30, Healthcare Associated Infections Program IP team member Pinky Suriben (HAI) and Santa Clara County Public Health staff member Melissa Schilling conducted a site visit, Licensing Department joined via FaceTime.

HAI provided additional recommendations and training for facility staff members.

Facility staff is responsible for implementing latest recommendations and providing HAI training for staff who were not present at the time of the call.

No deficiencies cited during this visit.

This report was reviewed with Executive Director Brisa Romero and an electronic copy was provided for signature on 10/26/2020.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2020
LIC809 (FAS) - (06/04)
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