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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202301
Report Date: 10/25/2020
Date Signed: 10/26/2020 08:13:18 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:
10/25/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mike Sneper & Brisa RomeroTIME COMPLETED:
02:30 PM
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On 10/19/20 Licensing Program Analyst (LPA) Ryker Heberle, Licensing Program Manager (LPM) Sarah Yip, Regional Manager (RM) Vivien Helbling, and Program Clinical Consultant (PCC) Helen Shi conducted a case management tele-visit via Facetime to follow up on a technical assistance tele-visit that occurred on October 19th 2020. LPA, LPM, RM, and PCC met with facility Administrators Brisa Romero and Michael Sneper (Admins).

Admins gave Licensing a tour of the facility. during the inspection, PCC noted that all recommendations reported on the 10/18/2020 tele-visit had been implemented. PCC noted the following additional recommendations during inspection:

1. All dirty clothes and linen laundry needs to be bagged before it is placed in the laundry bin.

2. Laundry staff must don full PPE before handling dirty laundry and must remove PPE after laundry has been cleaned

3. Facility must incorporate Admin's new screening tracking form and establish an individual to report potential positives to management if detected.

4. Arrange dining room to fulfill social distancing practices and remove/block noncompliant seating

5. Establish randomized checks on staff to ensure proper understanding of doning and doffing PPE.


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: 10/25/2020
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: 10/25/2020
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6. Follow up with local public health for N95 fitting test.

These deficiencies must be addressed immediately.

No deficiencies cited during today's visit.

This report was reviewed with Administrator Brisa Romero and an electronic copy of the report was provided for signature on 10/25/2020
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2020
LIC809 (FAS) - (06/04)
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