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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803728
Report Date: 09/29/2021
Date Signed: 09/29/2021 12:45:17 PM

Document Has Been Signed on 09/29/2021 12:45 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:PALM VIEW RETREATFACILITY NUMBER:
486803728
ADMINISTRATOR:RIDOLFI, ELEINAFACILITY TYPE:
735
ADDRESS:150 BROADWAY STREETTELEPHONE:
(707) 652-2624
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 32CENSUS: DATE:
09/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:38 AM
MET WITH:Cecily Palma, AdministratorTIME COMPLETED:
12:39 PM
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Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Administrator, Cecily Palma (CP).The facility currently provides care for 19 clients some of which were out with staff for medical appointments.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Administrator; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found throughout the facility and to be last charged on 11/5/2020 at the time of the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with balanced meals and alternative options for clients. LPA conducted a sample file review and found all staff to have current CPR and 1st Aid certification on file.

Toxins are stored in a locked facility laundry room and maintenance closets. There was a supply of hygiene products and paper products available and kept in client individual bedrooms. Facility provides all hygiene product to clients when requested. All client bedrooms have lighting & appropriate furnishings. Medications and facility records are secured in the facility medication room with pin pad access. LPA measured water at faucets accessible to clients which measured at 106.1 and 108.8 which is within Title 22 regulations between 105 and 120 degrees F. Facility is currently awaiting Technical Support Program services to be implemented.


Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2021
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: PALM VIEW RETREAT
FACILITY NUMBER: 486803728
VISIT DATE: 09/29/2021
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Infection Control:
Facility has submitted a mitigation program plan which has been reviewed. Majority of clients and some staff are vaccinated with no symptoms. Surveillance testing of unvaccinated staff are conducted on a weekly basis. Posters have been placed at the front door and throughout the facility, along with a station at main entrance with a sign in sheet, hand sanitizer and other items designated for visitors and staff. Staff and clients are screened for temperature and symptoms on a daily basis and recorded.

Cecily Palma's Administrator Certificate, 6031922740 is effective until 2/25/2022. All fees are current as of this time.

LPA requested for the following forms to be submitted to CCL by due date 8/1/2021:

- Updated LIC500 Personnel Report
- Updated LIC610E Emergency Disaster Plan
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
LIC809 (FAS) - (06/04)
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