Palm Valley Care Home VI

Type of visit: Required - 1 Year

On 7/14/2025, Licensing Program Analyst, Arvin Villanueva (LPA) arrived unannounced at this facility to conduct the annual inspection visit. LPA met with Licensee/Administrator Gerwin Sicat (S1), and stated the purpose of the visit. Overview: Facility is a one-story home located in a residential neighborhood. Facility is licensed to serve up to 6 elderly residents who may be ambulatory and/or non-ambulatory. Facility has an approved hospice waiver for up to 4 residents. Currently, there are no residents in care receiving hospice care. Facility does not handle resident cash resources. Initial Observation: Upon arrival LPA observed 2 staff on duty (S1 and S2) with 4 resident in care (R1, R2, R3, R4). Per interview with S2, residents are in their bedroom taking a nap. LPA observed required posters and facility license at the entrance. Room temperature was at 80 degrees Fahrenheit upon arrival. Physical Inspection: Areas inspected include, but not limited to, the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA inspected 4 of 6 resident bedrooms and were observed to be equipped with the required furniture and sufficient lighting throughout. 2 of 6 bedrooms are currently unoccupied. LPA measured the hot water temperature in the 1 of 2 bathrooms to be at 107 degrees Fahrenheit. In one of the bathroom, LPA observed the under the sink cabinet to be in disrepair as evidenced of the lock not functioning properly. Advisory was provided to licensee to make necessary repair. {Con't to 809-C} {Con't from 809} Fire extinguishers were observed in the kitchen area and hallway and were last inspected on 3/5/2025. Smoke and carbon monoxide detectors combination were observed throughout. LPA observed centrally stored medications, toxins, and sharp objects were kept locked and inaccessible to residents in care. In the kitchen area, LPA observed sufficient seven day non-perishable and two day perishable food supplies. Pantry was observed to be fully stocked with non-perishable food items. Proper storage of food items were observed. Kitchen refrigerator/freezer were observed to be clean. Outdoor area was inspected. LPA observed outdoor furniture for resident use. Ramps were observed to be in good repair at this time. Emergency walkways were observed to be unobstructed. Fence and gates were in good repair at this time. LPA observed a covered porch going to the backyard. Record Reviews: Review of 4 of 4 resident files (R1, R2, R3, R4) was conducted, include review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. Advisory was provided to update R1's Needs and Services Plan; it was last updated 3/24/22. A signed PRN Authorizations were needed for R3 and R4. Per S1, they are still trying to get their doctors to review and sign the form. Medication review of 2 residents (R3, R4) include review of physician orders for over-the-counter medications. No issues were noted at this time. Review of 3 staff files (S1, S2, S3) include review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. Per review and interview, S1 does not have a current Administrator Certificate. It was determined through record review that S1's Administrator certificate expired on 3/10/2025. Per interview, S1 submitted the application for renewal after the expiration of his Administrator Certificate. Per review of the he Community Care Licensing Division Administrator Certification Section confirmed that a S1's Administrator Certificate was received on 5/22/2025. LPA also reviewed fire drill/disaster drill records; facility conducts monthly drill. LPA was provided a copy of current Liability Insurance Certificate, LIC500 and LIC308 during this visit. Interviews: LPA interviewed 1 staff. Residents were not available for interview during this visit as they were taking a nap. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were cited. Exit interview was conducted with S1. A copy of the report and appeal rights were provided upon exit.the state’s words, verbatim · CDSS document, Jul 14, 2025

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 7/16/24, at 1:40pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived to the facility unannounced to conduct an annual required visit. LPA met with Administrator Gerwin Sicat (ADM) and stated the purpose of the visit. Present during this visit are 3 residents with 2 staff on duty. LPA and ADM toured the facility inside and out to ensure compliance with Title 22 regulations. LPA observed bedrooms, bathrooms, common areas, kitchen area, dinning area, and exterior areas. Facility is a one-story home located in a quiet residential neighborhood. Facility has 6 private resident bedrooms. At this time, 4 of 6 bedrooms are being occupied. Resident bedrooms were observed to be spacious to accommodate residents' belongings and each bedrooms has an exit to the outside. Two bathrooms were observed and both were equipped with grab bars, commode and non-skid flooring. Solid waste were properly disposed in close lid garbage cans. Medications, toxins, sharps and other dangerous items were observed to be locked and inaccessible to residents. Carbon monoxide/smoke detectors combo were observed, tested and found to be operable. Kitchen area was observed to be clean, sanitary and free of clutter. Technical assistance was provided for licensee to obtain thermometers for the refrigerator and freezers to ensure regulatory temperature is maintained. Fire extinguishers with last serviced on 3/5/24 and was observed to be in working condition. The facility temperature was comfortable at 80*degrees. Hot water temperature in one bathroom was measured at 107*F. The facility was observed to have an adequate supply of food to meet the requirements of 2 days of perishable foods and 7 days of non-perishables foods. An emergency supply of food was also observed. The facility has a covered patio with outdoor seatings for residents. Technical assistance was provided to replace the right side gate latch with code complaint self-closing latch. Technical assistance was also provided to clear out any tools and store them in their storage shed. Fences and gates on both side of the home were observed to be in good repair. Screens are also maintained and in good repair. {Page 1} LPA conducted record review of 4 staff files and 4 resident files. Technical assistance was provided for licensee to maintain all required documents in the facility. 4 of 4 staff were observed to have current 1st Aid/CPR certificates. Technical assistance was also provided to document their quarterly fire drills. Medication review of 2 of 4 residents was conducted and in compliance. LPA requested the following documentation: LIC 500, LIC 308, LIC 610D, current Liability Insurance LPA also reviewed facility's infection control plan and requested licensee to submit to the Department for further review. Per California Code of Regulations (CCR), Title 22, no deficiencies were observed during today's visit. An exit interview was held, and a copy of the report was provided. {Page 2}the state’s words, verbatim · CDSS document, Jul 16, 2024

The state marks this report as 6 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.