435202301-4-28-2021-26-AS-RHEE-C2HVEK-20210428162226

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202301
Report Date: 11/13/2020
Date Signed: 04/28/2021 04:22:30 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, CAMPBELL		FACILITY NUMBER:	435202301
ADMINISTRATOR:	SNEPER, GARRY		FACILITY TYPE:	740
ADDRESS:	3333 SOUTH BASCOM AVENUE		TELEPHONE:	(408) 559-8301
CITY:	CAMPBELL	STATE: CA	ZIP CODE:	95008
CAPACITY:	48	CENSUS: 22	DATE:	11/13/2020
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Brisa Romero, Michael Sneper, Garry Sneper		TIME COMPLETED:	10:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 11/13/20 Licensing Program Analyst (LPA) Ryker Heberle, Regional Manager (RM) Vivien Helbling, and Program Clinical Consultant (PCC) Helen Shi conducted a technical assistance tele-visit via Facetime to follow up on a technical assistance tele-visit that occurred on 11/9/2020. LPA, RM, and PCC met with facility Executive Director Brisa Romero (Admin). Admin gave Licensing a tour of the facility. Tour started in the facility courtyard, where The Department observed a medicine cart located directly next to the entry gate. Medcart is now being used as universal check in station as opposed to the front desk. Medcart was observed to be stocked with PPE, hand sanitizer, and universal symptom screening forms. The Department was given a tour of the dining area, back patio break area, TV room, and staff break room. These common areas were observed to adequately meet social distancing and infection protection standards. The department requested to be shown the bathrooms in the former infection wing. Bathrooms with bathing capabilities had reusable towels despite HFEN recommending that towels be removed during previous tele-visit. Admin clarified that they are currently waiting on the delivery of cabinets to store towels. LPA recommended Admin temporarily relocate towels until cabinets arrive. Admin indicated that the staff had begun fit testing for N95s, but some staff members had not yet been tested. PCC stressed the importance of fit testing to Admin and encouraged Admin to get the rest of the staff tested as soon as possible. Report continued on 809-C

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020

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: 11/13/2020

NARRATIVE

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Resident was observed in their room eating. Resident finished the majority of their meal, was well groomed, and seemed in good spirits.

Department observed two residents resting in their shared room. Residents were adequately distanced and room was set up to adhere to social distancing specifications.

While observing laundry room, department noted that cleaning solution had a current date and time stamp.

Adequate supplies were observed in the facility offices and basement.

No deficiencies were cited on this tele-visit. Exit interview conducted.

This report was reviewed with Executive Director Brisa Romero and an electronic copy was provided for signature on 11/13/2020.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020

LIC809 (FAS) - (06/04)

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