<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803728
Report Date: 02/16/2023
Date Signed: 02/16/2023 03:42:41 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/19/2022 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20220919121515
FACILITY NAME:PALM VIEW RETREATFACILITY NUMBER:
486803728
ADMINISTRATOR:CECILY PALMAFACILITY TYPE:
735
ADDRESS:150 BROADWAY STREETTELEPHONE:
(707) 652-2624
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY:32CENSUS: DATE:
02/16/2023
UNANNOUNCEDTIME BEGAN:
02:04 PM
MET WITH:Resident Care Coordinator, Na'Dira SerquinaTIME COMPLETED:
03:55 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Reporting requirements
Neglect/Lack of supervision
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 2/16/2023 Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint findings and was greeted by Care Coordinator, Na'Dira Serquina. LPA and the Department toured the facility, reviewed client medical, facility and licensing records, obtained written statements from outside parties and made observations during the course of the investigation.

Complaint alleges facility failed to follow Title 22 reporting requirements regarding client incidents. Based on LPA review of records, it was found that client (C1) was admitted to Sutter Vallejo hospital on 9/6/2022 and 9/30/2022 for medical services. On 9/30/2022, C1 was also found to have been admitted to Sutter Vallejo with no staff supervision. LPA found that the facility had not submitted any incident reports to Community Care Licensing pertaining to C1 being admitted to Sutter Vallejo for medical treatment or from C1 being left unsupervised in the community, therefore the allegation is found to be SUBSTANTIATED. Continued onto LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/19/2022 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20220919121515

FACILITY NAME:PALM VIEW RETREATFACILITY NUMBER:
486803728
ADMINISTRATOR:CECILY PALMAFACILITY TYPE:
735
ADDRESS:150 BROADWAY STREETTELEPHONE:
(707) 652-2624
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY:32CENSUS: DATE:
02/16/2023
UNANNOUNCEDTIME BEGAN:
02:04 PM
MET WITH:Resident Care Coordinator, Na'Dira SerquinaTIME COMPLETED:
03:55 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Neglect/Lack of supervision resulting in client sustaining an injury
Personal rights
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 2/16/2023 Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint findings and was greeted by Care Coordinator, Na'Dira Serquina. LPA and the Department toured the facility, reviewed client medical, facility and licensing records, obtained written statements from outside parties and made observations during the course of the investigation.

Complaint alleges neglect/lack of supervision resulting in client sustaining an injury. Based on Department review of client (C1) medical records; discharge paperwork from Sutter Vallejo hospital dated 9/6/2022, indicated that a physical assessment was conducted for C1, but there were no signs of injury including deformities, contusions, abrasions, penetrations or perforations, burns, tenderness, lacerations and swelling (DCAPBRLS). There was no corroborating evidence to support allegation of C1 sustaining injury therefore the allegation is UNSUBSTANTIATED. **Continued onto LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20220919121515
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PALM VIEW RETREAT
FACILITY NUMBER: 486803728
VISIT DATE: 02/16/2023
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
26
27
28
29
30
31
32
Complaint alleges the facility violated C1’s personal rights regarding Palm View Retreat Staff speaking inappropriately with C1. Based on written statements from multiple outside witnesses (W1, W2, W3 & W4), LPA found that W3 had observed on 9/6/2022; Palm View Retreat staff (S1) yelling at C1 “we gotta go” addressing C1 to get into the facility vehicle to return to Palm View Retreat. However, statement from witnesses, W1, W2 & W4 did not indicate seeing this interaction between Palm View Retreat staff, S1 and C1. Due to inconsistency of statements and lack of corroborating evidence, the allegation is found to be UNSUBSTANTIATED.

Allegation, neglect/Lack of supervision resulting in client sustaining an injury and


personal rights of clients violated, are found to be unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Appeal Rights given.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20220919121515
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PALM VIEW RETREAT
FACILITY NUMBER: 486803728
VISIT DATE: 02/16/2023
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
26
27
28
29
30
31
32
Complaint alleges neglect/lack of supervision resulting in client (C1) left in the community unattended by staff. Based LPA's review of C1’s Physician’s Report; C1 is not allowed to leave the facility unassisted. Based on Department review of C1's hospital medical records, it is indicated that C1 had been admitted to Sutter Vallejo on 9/30/2022 at approximately 0242 hours by means of walking with no Palm View Retreat staff present or in line of sight. In addition, C1 was noted by Sutter Vallejo hospital staff that C1 had been discharged at approximately 0422 hours and "left without being seen", thus indicating a lack of supervision. Therefore the allegation is found to be SUBSTANTIATED.

Allegation, facility failed to follow reporting requirements and neglect/lack of supervision are found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Appeal Rights Given
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20220919121515
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PALM VIEW RETREAT
FACILITY NUMBER: 486803728
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/17/2023
Section Cited
HSC
1569.269(a)(6)
1
2
3
4
5
6
7
Enumerated rights; severability(a(6) - ..To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This was not met as evidence by**
1
2
3
4
5
6
7
Licensee to submit a statement understanding HSC 1569.269(a)(6) & will be in future compliance. Additionally, submit a written plan of how they will ensure clients individual needs are met.
8
9
10
11
12
13
14
Based on C1 medical record review, C1 was found to have been admitted to Sutter Vallejo hospital on 9/30/22 with no facility staff providing supervision. This is an immediate health and safety risk to clients in care.
8
9
10
11
12
13
14
Statement and detailed plan to be submitted to CCL by POC due date 02/17/2023.
Type B
02/23/2023
Section Cited
CCR
80061(b)(1)(E)
1
2
3
4
5
6
7
Reporting Requirements(b)(1)(E) - Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. This was not met as evidence by**
1
2
3
4
5
6
7
Licensee to submit a statement understanding regulation 80061 & will be in future compliance. Additionally, submit a written plan of how they will ensure reporting requirements are met along with in service
8
9
10
11
12
13
14
Based on a review of facility and Licensing records, facility did not submit incident reports regarding C1 being admitted to Sutter Vallejo for hospital treatment or for occurrence of C1 left unsupervised. This is a potential health & safety or personal rights risk to clients in care.
8
9
10
11
12
13
14
training for all staff and management. Statement and detailed plan to be submitted to CCL by POC due date 02/17/2023. Completed training with staff signatures to be submitted by POC due date 2/23/2022
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5