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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803728
Report Date: 08/09/2024
Date Signed: 08/09/2024 02:36:21 PM

Document Has Been Signed on 08/09/2024 02:36 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/
DIRECTOR:		HARRIS, DAE'JANIQUEFACILITY TYPE:
735
ADDRESS:150 BROADWAY STREETTELEPHONE:
(707) 652-2624
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 32CENSUS: 31DATE:
08/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH: DAE'JANIQUE HARRIS, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived at approximately 9:45 AM at Palm View Retreat on 08/09/2024 to conduct an unannounced Annual Inspection. LPA was buzzed into the facility and asked to sign in. Administrator Dae'Janique Harris came and introduced herself and allowed LPA into the facility.

LPA began the inspection with a review of files. Five of five staff files were found to have all necessary information, although First Aid training records needed to be updated. LPA reviewed five of five resident files and found those to be appropriate and complete during the review.

LPA and Administrator toured the facility. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Seven (7) fire extinguishers were found to be last serviced on October 5, 2023 and all were fully charged at the time of the inspection. All smoke detectors and carbon monoxide detectors are hardwired to the nearest Fire Authority. The System was last inspected by National Fire Alarm Company on September 12, 2023 without issue. Water temperature in residents' bathrooms, medication room and shower room were within acceptable range of 105 to 120 degrees F. There was an ample supply of perishable and non-perishable foods located in the kitchen. The menu is attractive and varied and is posted for residents; special provisions are made for residents with special dietary needs. LPA observed the lunch service and saw residents were very satisfied with the food, quality and quantity. Meals are served in the dining room three times a day, as well as 2 snacks and fresh fruit available during the evening hours. A hydration station is also set up at all times. Activity Calendar was observed. The activity/TV room had space for a variety of activities. The house phone was also in this area.
Medications were centrally stored and locked.
Continued on 809-C.....
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2024
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: 08/09/2024
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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 were supplied with paper towels and hand soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in shower rooms. A tour of residents' bedrooms was conducted, and found to have appropriate furnishings.

Staff conduct regular outings for residents. The fenced back yard of the facility is well maintained and attractively landscaped. There is plenty of seating with shade and a smoking area.

LPA requested the following:

Resident Roster
Up-to-date Lease Agreement

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 Administrator.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC809 (FAS) - (06/04)
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