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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202301
Report Date: 11/18/2020
Date Signed: 04/28/2021 04:23:11 PM

Document Has Been Signed on 04/28/2021 04:23 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: 22DATE:
11/18/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Brisa RomeroTIME COMPLETED:
10:10 AM
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On 11/18/20 Licensing Program Analyst (LPA) Ryker Heberle and Program Clinical Consultant (PCC) Helen Shi conducted a case management tele-visit via Facetime to follow up on the readmission of a resident (R1) following a month long absence. LPA and PCC met with facility Executive Director Brisa Romero (Admin).

Admin indicated to The Department that the last time R1 was tested for COVID-19 was on 10/23/2020. R1 returned to the facility on 11/17/2020. Admin gave The Department a tour of the isolation area. Isolation area was located across the hall from the communal dining area. Isolation area was observed to not have covered trash receptacles located outside of resident rooms. Isolation area did not have a doffing and donning station for PPE. Rooms adjacent to R1's room were observed to be empty. R1's isolation room has its own bathroom.

Upon entry into room, The Department observed R1 being assisted by facility staff. Facility staff member was noted to not be wearing full PPE, only a mask, gloves, and face shield.

Deficiencies were observed and cited under Title 22, Division 6, Chapter 8. See LIC 809D for the deficiencies cited.

A civil penalty of $250.00 is being assessed for repeat violation under the same Personal Rights regulation Sec. 87468.1(a)(2) issued on 10/28/20.

This report and the appeal rights were discussed with Executive Director Brisa Romero.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2020
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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Document Has Been Signed on 04/28/2021 04:23 PM - It Cannot Be Edited


Created By: Ryker Heberle On 11/18/2020 at 11:13 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PALM VILLAS, CAMPBELL
FACILITY NUMBER: 435202301

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2020
Section Cited
CCR
87468.1(a)(2)

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87468.1(a)(2) Personal Rights - To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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CORRECTED: Day of report, Admin sent pictures showing placement of trash receptacles and PPE stoking in a newly designated doffing and donning station.
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A resident that had been transferred out of the facility as late as 10/19/20 was not placed under quarantine upon readmission to the facility.
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Type A
11/18/2020
Section Cited
CCR87468.1(a)(2)

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87468.1(a)(2) Personal Rights - To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Facility must write a plan of action describing facility plan to correct the deficiency . Plan of correction due date is 11/19/20
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Staff member was observed not wearing full PPE when providing direct assistance to resident.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:Ryker Heberle
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2020


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Document Has Been Signed on 04/28/2021 04:23 PM - It Cannot Be Edited


Created By: Ryker Heberle On 11/18/2020 at 11:31 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PALM VILLAS, CAMPBELL
FACILITY NUMBER: 435202301

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2020
Section Cited
CCR
87468.1(a)(2)

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87468.1(a)(2) Personal Rights - To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Facility must write a plan of action describing facility's plan to correct the deficiency . Plan of correction due date is 11/19/20
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Resident was readmitted into facility on 11/17/2020 despite not being tested for COVID since 10/23/20. Resident was transferred out of facility some time between 10/15/2020 and 10/19/2020.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:Ryker Heberle
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2020


LIC809 (FAS) - (06/04)
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