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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803728
Report Date: 06/14/2022
Date Signed: 06/14/2022 05:14:51 PM

Document Has Been Signed on 06/14/2022 05:14 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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:
06/14/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Dae Harris, Assistant DirectorTIME COMPLETED:
05:20 PM
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On 6/14/2022 LPA Tobola conducted a Case Management for the purpose of a Quarterly Non-Compliance visit and was greeted by Assistant Director, Dae Harris.

LPA conducted a spot medication count with med-tech staff Tati Burson (TB) and Assistant Director, Dae Harris. All medications are recorded on an electronic Medication Administration Record (MAR). Facility staff also records narcotics on a written version of the MAR. LPA reviewed client (C1's) physical written MAR and found that the narcotic medication count did not match the electronic count. However, during additional inspection of the electronic MAR, LPA found that the count matched the actual medication count observed in C1's prescribed bubble pack. LPA issued Technical Violation and discussed with Assistant Director a plan of action to ensure medication recording process is clear and consistent.

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2022
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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