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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803728
Report Date: 10/16/2023
Date Signed: 10/16/2023 02:29:47 PM

Document Has Been Signed on 10/16/2023 02:29 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: 31DATE:
10/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Resident Care Coordinator, Nye SerqueniaTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Palm View Retreat for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Resident Care Coordinator, Nye Serquenia, and was granted access into the facility.

LPA and Resident Care Coordinator toured the facility. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on October 2023 at the time of the inspection. All smoke detectors and carbon monoxide detectors are hardwired to the nearest Fire Authority. Water temperature in clients bathroom measured at 116 degrees, within acceptable range of 105 to 120 degrees F. There was sufficient perishable and non-perishable foods located in the kitchen. There are special provisions made for individuals with special dietary needs. Food menu was presently available for viewing during the inspection. Activity Menu was observed in the activity room. Medications were centrally stored and locked. Cleaning products and other toxins are locked and inaccessible to clients in care. There was a supply of Linens, cleaners, hygiene products and paper products available for clients. All bathrooms designated for clients in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms in resident’s rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of all clients bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing. During the Required 1 year inspection, LPA reviewed 5 of 5 staff files and found those to be appropriate during the review. LPA reviewed 5 of 5 resident files and found those to be appropriate during the review. Emergency Disaster Plan, Infection Control Plan and Medications will be reviewed at a later date and time.

No deficiencies were observed or cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was given to the Resident Care Coordinator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2023
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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