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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202301
Report Date: 06/14/2024
Date Signed: 06/14/2024 03:56:32 PM


Document Has Been Signed on 06/14/2024 03:56 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
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: 40DATE:
06/14/2024
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
11:38 AM
MET WITH:Jimena PulidoTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Collateral visit and Met with the facility Medication Manger Jimena Pulido (MM).

The purpose of the visit was to interview resident R1 and to collect R1's medical records as part of a complaint investigation of another licensed facility..

During the visit, LPA interviewed MM, resident R1, and 3 staff (S1 - S3).

LPA toured the bedroom of R1 with MM.

LPA requested R1's medical records and medical notes.

No deficiencies cited today.

The report was provided to MM for signature. A copy of the report was provided to MM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024
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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