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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803728
Report Date: 12/29/2022
Date Signed: 12/29/2022 12:36:52 PM

Document Has Been Signed on 12/29/2022 12:36 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:ELEINA RIDOLFIFACILITY TYPE:
735
ADDRESS:150 BROADWAY STREETTELEPHONE:
(707) 652-2624
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 32CENSUS: 27DATE:
12/29/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:38 AM
MET WITH:Dae Harris, AdministratorTIME COMPLETED:
12:45 PM
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On 12/29//2022 Licensing Program Analyst (LPA), Tobola conducted a Case Management for the purpose of a Quarterly Non-Compliance visit and was greeted by Administrator, Dae Harris.

LPA conducted a spot medication count of both narcotic and general prescription medication for 6 clients with med-tech staff. LPA and med-tech staff reviewed the electronic centrally stored medication record system and found all general prescription medications to be in order. In addition, LPA and med-tech reviewed the narcotic medication administration record both electronically and on hard copy written records confirming that the medications have been administered and recorded in order.

LPA Tobola found that all med-tech staff are trained to conduct continuous medication reviews and record any expired or expiring medication for preparation of medication disposal. LPA was informed of the facility's medication disposal protocol in which either two med-techs or a med-tech and Administrator are to be present as witnesses when disposing of medications properly. A locked medication disposal bin is located in the secured medication room and with medications picked up for destruction by pharmacy.

In addition, LPA Tobola conducted a sample staff file review for med-tech staff on medication administration training. Training is conducted primarily on the Relias electronic system with additional monthly in-service group training. During the training record review LPA and Administrator found that majority of staff Relias accounts have been deactivated and were unable to access records at this time. LPA and Administrator contacted the facility Human Resources Staff, Danny Ly (DL) and was informed that the company is undergoing a change in training records maintenance. Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2022
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: 12/29/2022
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DL stated that all American Housing Inc. facility staff have previously been under a single Relias account. However, the company is currently in the process of separating staff into their respective individual facilities. DL also stated that all training conducted within the last several months may be pending on the Relias database due to this change.

LPA Tobola issued a Technical Assistance and agreed with Administrator to review staff medication training documents at a later date once the system is updated.

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC809 (FAS) - (06/04)
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