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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803728
Report Date: 06/23/2023
Date Signed: 06/23/2023 04:43:04 PM

Document Has Been Signed on 06/23/2023 04:43 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:HARRIS, DAE'JANIQUEFACILITY TYPE:
735
ADDRESS:150 BROADWAY STREETTELEPHONE:
(707) 652-2624
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 32CENSUS: 29DATE:
06/23/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Dae Harris, AdministratorTIME COMPLETED:
03:45 PM
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On 6/23//2023 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 toured the facility and conducted a spot medication count of both narcotic and general prescription medication for 3 clients with Wynn Brewer, med-tech staff. LPA and med-tech staff manually counted medication based on start date and record. Upon review of client's (C1) medication records, LPA found that the prescription labeling for medication Divalproex Sodium 500mg does not match the updated prescription order for client requiring client to take 1 tablet 3 times per day. In addition, LPA conducted a sample review of the Centrally Store Medication Records and found several missing start dates on client records. Facility does include start dates directly on prescription packets however, information is to be properly reconciled on Centrally Store Medication Records. Technical Advisory issued. LPA requested for medication room audit to reconcile records. LPA to review during next NCC inspection.


No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2023
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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