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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202301
Report Date: 12/11/2020
Date Signed: 04/28/2021 04:23:30 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, CAMPBELLFACILITY NUMBER:
435202301
ADMINISTRATOR:SNEPER, GARRYFACILITY TYPE:
740
ADDRESS:3333 SOUTH BASCOM AVENUETELEPHONE:
(408) 559-8301
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:48CENSUS: 24DATE:
12/11/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Brisa RomeroTIME COMPLETED:
10:40 AM
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On 12/11/20 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. LPA, RM, and PCC met with facility Executive Director Brisa Romero (Admin).

Admin gave Licensing a tour of the facility, including the entry courtyard, main hallway, communal dining area, shower rooms, isolation area, 2 resident rooms, 2 public bathrooms, staff break room, laundry room, back courtyard and TV room

Facility nurse demonstrated donning and doffing procedure for entry into isolation area

The department observed residents participating in various activities in the communal dining area, residents appeared healthy and well groomed. The department interviewed two residents, who were both in good spirits. Residents in dining room were not observed to be wearing masks.

PCC made the following recommendations:
  1. Remind residents to wear masks outside of rooms
  2. Request LVN to emphasize seal test and use of hand sanitizer during donning and doffnig procedure
  3. Put up hand washing posters in resident bathrooms

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 12/11/2020
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2020
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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