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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803728
Report Date: 12/29/2021
Date Signed: 12/30/2021 04:02:45 PM

Document Has Been Signed on 12/30/2021 04:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
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: 22DATE:
12/29/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Tanisha Kenion, Care CoordinatorTIME COMPLETED:
03:15 PM
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On 12/29/2021 LPA Tobola conducted a Case Management for the purpose of a Quarterly Non-Compliance visit and was greeted by Care Coordinator, Tanisha Kenion. LPA conducted a tour of the facility and found it to be clean and at a comfortable temperature. LPA was informed of a damaged bedroom window located in facility Room 3. The bedroom is currently vacant and the window is closed off for pending repair.

The facility has contracted with an outside company to repair the window but due to inventory supply shortages and specialized parts for the replacement window; the repairs have been postponed and scheduled for February 2022. Facility will notify CCL once the repairs are completed.

LPA also conducted a spot medication count for 3 of 3 clients and found all medications and administration count to be in order. LPA was informed that there currently 9 med-techs; 2 of which are currently in training for additional support. Care Coordinator stated that medication room audits are now conducted randomly per month by Director, Cecily Palma. In addition, Care Coordinator has implemented medication monitoring for determining required medication refills. Care Coordinator also plans to develop medication count auditing form for medtech staff to conduct medication counts and monitoring more frequently.

LPA was informed that TSP services are to begin their in the facility in February 2022.


No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2021
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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