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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803728
Report Date: 10/24/2023
Date Signed: 10/24/2023 11:20:54 AM

Document Has Been Signed on 10/24/2023 11:20 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: 31DATE:
10/24/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Dae'Janique Harris
Resident Care Coordinator, Nye Serquenia		TIME COMPLETED:
11:30 AM
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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 Administrator, Dae'Janique Harris. LPA was granted access into the facility.

During the Case Management-Annual Continuation, LPA reviewed Medication Orders for 5 clients in care. LPA conducted staff and client interviews. LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms of COVID-19 + in the facility. Emergency Disaster Plan was discussed. However, LPA observed that the Emergency Disaster Plan has not been reviewed since 2021 (See LIC 9102-Technical Violation) LPA requested the following documents to be sent:

LIC 500-Personnel Report
LIC 308-Designation of Responsibility
Liability insurance
Control of Property
Client Roster

No deficiencies were cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was given to the facility Resident Care Coordinator
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023
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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