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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200399
Report Date: 11/15/2022
Date Signed: 11/15/2022 05:46:38 PM


Document Has Been Signed on 11/15/2022 05:46 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:PALM TREE CARE HOMEFACILITY NUMBER:
079200399
ADMINISTRATOR:WANG, LISAFACILITY TYPE:
740
ADDRESS:712 MCLAUGHLIN STREETTELEPHONE:
(510) 229-2888
CITY:RICHMONDSTATE: CAZIP CODE:
94805
CAPACITY:6CENSUS: 4DATE:
11/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Lisa Wang, AdministratorTIME COMPLETED:
02:00 PM
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On 11/15/2022 at 01:05 PM, Licensing Program Analyst (LPA) L. Holmes conducted an unannounced Infection Control Inspection. LPA explained the purpose for the visit to Lisa Wang, Administrator.

Facility has a COVID-19 mitigation plan on file. LPA requested a staff and resident roster. LPA observed a screening station at the entry that contained thermometer, hand sanitizer, COVID-19 signage, and a visitor sign-in log. LPA toured the facility including, but not limited to common areas, bathroom, bedrooms, kitchen, garage, and backyard. LPA observed masks, cough etiquette, social distancing and hand washing signs posted throughout. Add covered garbage can to shared bathroom. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All hand washing stations were equipped with soap, paper towels and garbage cans. There is a surplus of PPE stored in the garage of the facility that is accessible to all care staff. Hot water temperature in the shared residents' bathroom was measured at 110.8 degree Fahrenheit (F) and the facility's temperature was at a 70 degree. Fire extinguishers were observed full and last inspected on 08/03/2022. Smoke/Carbon Monoxide detectors were observed operational and in every room; first aid kits are complete.

The following forms are to be updated and submitted to CCLD:
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC610E Emergency Disaster Plan (Reviewed)
-An updated copy of Administrator Certificate(s) (Reviewed)

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2022
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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