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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803728
Report Date: 09/20/2022
Date Signed: 09/20/2022 01:32:20 PM

Document Has Been Signed on 09/20/2022 01:32 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: 23DATE:
09/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:47 AM
MET WITH:Elaina Ridolfi, AdministratorTIME COMPLETED:
01:30 PM
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On 9/20/2022, Licensing Program Analyst (LPA) D. Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Administrator, Cecily Palma (CP).The facility currently provides care for 23 clients all of which were present the time of visit.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Administrator; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found throughout the facility and to be last charged on 11/17/2021 at the time of the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with balanced meals and alternative options for clients. LPA conducted a sample file review and found all staff to have current CPR and 1st Aid certification on file.

Toxins are stored in a locked facility laundry room and maintenance closets. There was a supply of hygiene products and paper products available and kept in client individual bedrooms. Facility provides all hygiene product to clients when requested. Facility has also requested for client restrooms to be equipped with paper towel dispensers/holders. All client bedrooms have lighting & appropriate furnishings. Medications and facility records are secured in the facility medication room with pin pad access. LPA measured water at faucets accessible to clients which measured between 115.3 and 118.7 degrees F which is within Title 22 regulations between 105 and 120 degrees F.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/20/2022
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NCC Inspection:
Facility is currently under Non-Compliance and requires quarterly meetings/inspections for review of medication count and facility grounds. Facility grounds were inspected and found to be in good repair. Communal client restroom was found to be out of order due to minor plumbing backup issue. Item has been noted and will be addressed and repaired today. Additional communal restroom located in the hallways as well as multiple shared restrooms in client bedrooms, all of which found to be clean and in good repair. Spot medication count was conducted with medtech for several clients. Facility utilized electronic Medication Administration Record with all items found to be in order. In addition, LPA was informed that several DSP staff are currently being trained for back up medtech to support the current 5 staffed medtechs. No deficiencies cited from NCC visit.

Infection Control:
Facility has submitted an Infection Control Plan to CCLD for review. All residents and staff are vaccinated with no symptoms. Individuals that are not vaccinated have exceptions on file. Posters have been posted throughout the facility for staff and residents ensuring COVID procedures. Facility has a station at main entrance for screening, hand sanitizer and other items designated for visitors and staff. Staff and residents are observed for symptoms and temperature on daily basis or based on change of condition.

No deficiencies cited during today's visit.

LPA requested the following documents be sent to CCL by COB 9/27/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility resident’s/Resident’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022
LIC809 (FAS) - (06/04)
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