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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202301
Report Date: 04/26/2021
Date Signed: 04/28/2021 04:24:13 PM

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: 28DATE:
04/26/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Garry Sneper, Mike Sneper, Brisa RomeroTIME COMPLETED:
11:35 AM
NARRATIVE
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Licensing Program Analyst Ryker Heberle (LPA), Licesnsing Program Manager Sarah Yip (LPM), and Regional Manager Vivien Helbling (RN) conducted a collaborative tele-visit meeting with facility administrator Garry Sneper (Admin), along with additional facility administrative staff Mike Sneper and Brisa Romero.

During the meeting, RN elaborated on the stipulation order regarding Forever Young's license revocation, which has been stayed with probation from April 14th 2021 to April 14th 2023 pursuant to the following conditions:

A) Facility shall operate strictly within regulation
B) Facility shall grant The Department discretion and inspection authority
C) Facility must maintain compliance with personal rights, reporting requirement, and allowable health condition regulations
D) Facility must maintain strict compliance with COVID-19 policies and regulations
E) Within 60 days of execution of this stipulation, Facility must employ infection control nurse and COVID-19 mitigation plan. Admin indicated that the facility already maintains an infection control nurse on staff and that they will resubmit mitigation plan
F) Facility shall be keep clean, safe, sanitary, and in good repair
G) Facility shall maintain home health agreements for all clients
H) Within 90 days of execution of this stipulation, facility must provide training for all staff on COVID-19 infection control via medical professional and provide training record to The Department
I) This stipulation must be posted in a conspicuous place within the facility for the duration of probation
Continued in 809-C
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021
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: 04/26/2021
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The revocation of Admin's administrator certificate shall also be stayed with probation from April 14th 2021 to April 14th 2023. Admin shall be granted a probationary certificate pursuant to the following conditions:

A) Admin shall complete 20 hours of training in addition to any training courses required to maintain administrator certificate. This training shall be completed during the second year of Admin's probation
B) The stay of Admin's certificate shall only apply to facilities currently operated by Forever Young Inc. Admin cannot act as administrator of any other facilities during probation

RN also went into further detail on the remaining sections of the stipulation including future application for a license registration certification or approval, tolling of probationary period, completion of probation, violation of stipulation term, Department's authority, monitoring fee, waiver of hearing rights, waiver of appeal/modification rights, waiver of claims, public record, signatures, counterparts, effective date, no oral modification, and representations RE: corporate licensee.

RM asked meeting participants if they had any questions or required any further clarification on the conditions of the stipulation order. Admin asked for clarification on monitoring fees. Upon receiving answer from RN, all meeting participants indicated that they understood the stipulation order.

Admin inquired about whether the revocation status of Palm Villas, Campbell would be removed from the website. RN indicated that the matter is currently being resolved by legal team.

No deficiencies cites during this visit. This report was reviewed with Garry Sneper, Administrator, and a copy of this report was provided electronically for signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021
LIC809 (FAS) - (06/04)
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