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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202301
Report Date: 08/20/2021
Date Signed: 08/25/2021 08:14:06 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: 40DATE:
08/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:Brisa RomeroTIME COMPLETED:
03:20 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 08/20/2021 at 1:28pm. LPA met with facility administrator Brisa Romero (Admin).

LPA toured the facility, including courtyard, front offices, medication room, dining hall, kitchen, TV room, all facility bathrooms, 5 resident rooms, kitchen, laundry room, front offices, storage room, and break room.

All staff members observed to be wearing masks. Hand washing, cough sneeze etiquette, and social distancing signs observed in all facility common areas. Facility observed to have designated entry point. Staff took LPA's temperature and screened for symptoms. LPA observed staff members signing in to facility and following COVID-19 precautions.

LPA observed all facility bathrooms to have adequate supply of paper supplies and soap. LPA observed that bathroom garbage cans as have lids. When inspecting facility, LPA noted that facility had over 30-days worth of N95s, gowns, gloves, face shields, and booties. Kitchen observed to have adequate supply of perishable and nonperishable food. Water temperature tested at 4 faucets in facility with temperature ranging from 110.3*F to 113.5*F.

No deficiencies cited during this inspection. This report reviewed with Administrator Brisa Romero and a copy of the signed report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
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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