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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803728
Report Date: 09/19/2023
Date Signed: 09/19/2023 11:57:35 AM

Document Has Been Signed on 09/19/2023 11:57 AM - 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: 26DATE:
09/19/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:57 AM
MET WITH:Dae Harris, AdministratorTIME COMPLETED:
12:15 PM
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On 9/19//2023 Licensing Program Analyst (LPA), Tobola conducted a Case Management for the purpose of a Quarterly Non-Compliance visit and was greeted by Administrator Assistant, Latrice Tramel. Administrator, Dae Harris arrived later in the visit

LPA toured the facility and conducted a spot medication count of both narcotic and general prescription medication for 3 clients with lead med-tech staff. All items were found to be in order with facility transitioning to input prescription information on electronic forms prior to printing out the Centrally Store Medication Records to improve consistency and legibility compared to previous handwritten forms.

During the tour LPA observed the facility van for client transportation located in the parking lot to have been burnt along with the surrounding bush and garden area. LPA was informed that an unknown outside individual had arrived at the facility at the early morning hours of 9/17/2023 at approximately 4:00am, and set fire to the facility van. LPA found that two of the client bedroom windows had shattered due to the fire. All clients located in the damaged bedrooms were relocated and unharmed from the event. LPA reviewed surveillance footage and requested for a copy. The Vallejo Fire Department conducted an investigation report at the time of incident and will be sending a copy of the report once completed. Vallejo Police Department was contacted the same date but did not arrive. At this time the facility is undergoing an investigation to determine the suspect of vandalism and arson. The facility had properly responded to the event and ensured all staff and clients were unharmed.

Administrator has scheduled maintenance services on 9/20/2023 to repair windows and any damages to the parking lot area. The van will also be inspected for insurance purposes and removed this week to prevent any further hazards. Although there stands a physical plant disrepair issue, all repair concerns have properly been addressed.

The facility is found to be in compliance at this time.

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2023
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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