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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202301
Report Date: 08/20/2024
Date Signed: 08/20/2024 02:07:57 PM


Document Has Been Signed on 08/20/2024 02:07 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:
08/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Garry SneperTIME COMPLETED:
02:15 PM
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Licensing Program Analysts (LPAs) Marcella Tarin and David Marrufo conducted an unannounced required 1 year visit and met with Administrator Garry Sneper. During visit LPAs toured the facility inside and out.

LPAs toured the facility kitchen area. LPAs observed a perishable food supply of at least 2 days and a nonperishable food supply of 7 days. LPAs observed storage area with cleaning supplies and tools. The storage area was locked and inaccessible to residents. LPAs toured 1 hallway bathroom and measured the water temperature to be 114 degrees Fahrenheit. The bathroom had functioning lights and available soap and paper towels. LPAs toured 7 resident rooms. Each room had working lights, and available bedding and clothing storage areas. LPAs toured the bathrooms in each bedroom and found them to have working lights, available soap and paper towels. Water temperatures in the toured resident bathrooms ranged from 114 degrees Fahrenheit to 119 degrees Fahrenheit. LPAs tested the smoke detectors in each room, and observed the smoke detectors to be functioning properly. The smoke detectors also function as carbon monoxide detectors. LPAs tested 1 hallway carbon monoxide detector and it functioned properly. LPAs observed 2 resident exits to be clear of obstruction, and 1 out 1 tested alarmed exit tested properly when tested.

LPAs reviewed 7 resident Centrally Stored Medication and Destruction Record (CSMDR). Each reviewed CSMDR was complete during visit. LPA's reviewed 7 resident records, R1-R7. Resident R2 and Resident R4 did not have Appraisal Needs and Service Plan. Resident R5 is missing the first page of the Safeguard for Property and Valuables form. LPAs reviewed 7 out of 7 staff records to be complete. The last conducted Fire Drill is recorded at 5/20/2024.

Advisory notes were issued. See LIC 9102 pages for more information. No deficiencies were cited as per California Code of Regulations Title 22.

This report was reviewed with Administrator Garry Sneper. A copy of this report was provided.
SUPERVISOR'S NAME: Jin JackieTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella TarinTELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
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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