Palm Valley Care III

Type of visit: Required - 1 Year

On 1/22/2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced at this facility to conduct the annual inspection visit. LPA initially met with staff on duty, Staff on duty, Joselyn Endrina (S1) and Benjamin Gatchalian (S2), and stated the purpose of the visit. The Administrator, Aida Gatchalian (AD), was notified and arrived shortly after with another staff member, Maria Magnolia Tolon (S3). AD was unable to be at the facility due to a condition and appointed S3 to assist with the inspection. Overview: Facility is a one-story house located in a residential neighborhood. Facility is licensed to serve up to 6 elderly residents, all 6 may be non-ambulatory. Facility has a hospice waiver granted for 3 residents. Facility does not have clearance for bedridden residents. Present upon arrival were 6 residents in care with the 2 staff on duty. Physical Inspection: Areas inspected include, but not limited to, the kitchen, dining, resident units/bedrooms, resident bathrooms, common areas and outdoor areas. LPA inspected 6 of 6 resident bedrooms. Bedrooms were observed to be in good repair at this time. LPA inspected 4 of 4 bathrooms. All bathrooms were observed to be cleaned, in good working condition, and equipped with grab bars and non-skid flooring. Fire extinguishers were observed. During this visit, a fire extinguisher professional arrived to conduct maintenance service. Smoke and carbon monoxide detectors were observed throughout. LPA observed centrally stored medications, toxins, sharp objects and other dangerous items were kept locked and inaccessible to residents in care. Magnetic keys were observed to be accessible, and advisory was provided to staff to keep them inaccessible to residents who are at risk if they have direct access to dangerous items. {1 of 2} In the kitchen area, LPA observed at least seven-day non-perishable and two-day perishable food supplies. Pantry was observed to be fully stocked with non-perishable food items. Kitchen refrigerator and freezer were in good working condition at this time. Additional refrigerator and freezers for food items stored in the detached garage. Advisory was provided to place thermometers inside the refrigerators and freezers to monitor temperature. Medications that require refrigeration are kept locked, with a child lock device, in a small refrigerator located in a separate room, pass the laundry room. Advisory was provided to staff to change the child lock to a more secure lock such as one with a pad lock or combination lock. Photo evidence was requested once obtained and installed. Outdoor area was observed. LPA observed shade area and 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 gate were in good repair. Record Reviews: LPA reviewed 2 staff files and 3 resident files. Review of 3 of 6 resident files, including but not limited to, review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. LPA did not review resident medications during this visit. Advisories were provided. Review staff files included, but not limited, background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. Advisories were provided. Review of fire drill/disaster drill records: facility conducts at least quarterly drills, and last drill was conducted on 1/10/26. Documents Requested: LPA requested a copy of current Liability Insurance Certificate, LIC500, LIC308 to be emailed to arvin.villanueva@dss.ca.gov. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were cited. Advisories were provided. Exit interview was conducted. A copy of the report was provided upon exit. {2 of 2}the state’s words, verbatim · CDSS document, Jan 22, 2026

The state marks this report as 16 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 12/20/2024 at 9:35am, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to this facility to conduct their required annual visit. LPA initially met with S1 and explained the purpose of the visit. The facility administrator, Gerwin Sicat was informed of the visit and informed is not able to come to the facility today and gave permission to staff on duty to sign this report. Present during this visit were 4 residents in care with 2 staff on duty (S1, S2). LPA evaluated the physical plant with S1 to ensure the health and safety of the residents in care. Areas inspected include but not limited to the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. The facility is a one-story home located in a residential neighborhood. Facility is fire cleared to retain/admit 6 residents with approved hospice waiver for 3 residents. Facility has 6 bedrooms, 6 of which was approved for non-ambulatory. Facility has 3 bathrooms for resident use. 1 of which is located in the master bedroom. LPA observed the facility to be free of odor, clean and in good repair at this time. LPA observed all resident bedrooms to be equipped with the required furniture and sufficient lighting throughout the facility. LPA inspected 3 of 3 bathrooms and were observed to be equipped with slip resistant flooring and overall in good repair at this time. Hot water temperature in 3 resident bathroom was measured between 116 and 119 degrees F. Room temperature was observed at 72 degrees F. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers were observed and were last inspected on 1/23/24. Smoke and carbon monoxide detectors were observed, 1 sample was tested and found operable. LPA observed centrally stored medications, toxins, and sharp objects were kept locked and inaccessible to residents in care. Fireplace was observed to be screened and non-operational at this time. {1 of 2} Outdoor areas were observed to be clean and clear of hazards at this time. No bodies of water was observed at this time. Fence and gates were observed to be in good repair at this time. LPA observed outdoor furniture and outdoor activity area was observed to be spacious for resident use. LPA provided Technical Advisory for licensee to obtain more activity supplies for residents to have options. Review of 2 sample resident files (R1, R2) which include review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. No issues were noted. Medication review of 2 sample residents which includes review of facility's medication log, centrally stored medication record, and physician orders for over-the-counter medications. No issues were noted at this time. Review of 2 sample staff files (S1, S2) include review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. Administrator Certificate is current. S2 was found to have fingerprint clearance but not associated to this facility. According to interview and record review of the posted Personnel Report, S2 was employed on 8/1/24. Per interview, S2's transfer request file was submitted to the Department via mail and email. License and/or Administrator did not confirm with the Department if S2 was associated prior to working at this facility. Facility conducts quarterly disaster drill and last drill was on 8/10/24. Facility does not have infection control plan at this time. LPA reviewed mitigation plan. LPA provided TA for licensee to submit an infection control plan by 12/23/24. LPA requested a copy of current Liability Insurance Certificate, LIC500 and LIC308 to be submitted by 12/23/24. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were observed during today's visit. Exit interview was conducted and a copy of the report was provided upon exit. {2 of 2}the state’s words, verbatim · CDSS document, Dec 20, 2024

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Annual Continuation

On 1/3/2024 at 10:15am, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility to conduct an unannounced Case Management-Annual continuation visit to continue with the Annual visit initiated on 12/27/2023. LPA initially met with staff on duty and explained the purpose of the visit. The facility assistant administrator, Grant Depositar was informed of the visit and arrived shortly after. Present during this visit were 6 residents in care with 2 staff on duty. During this inspection, LPA conducted an audit of facility files, 6 resident files, and 8 staff files for regulatory compliance. LPA completed resident interviews and 2 staff interviews. 6 out of 6 resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. 8 out of 8 staff files reviewed contained all required contents including health screening, TB results, current first aid/CPR, and initial and ongoing required trainings. Facility’s liability insurance is current per regulatory requirements. The facility is current on annual license fees. LPA reviewed facility’s disaster plan to ensure regulatory compliance. Facility conducts quarterly fire drills. Medication storage area was observed to be locked and inaccessible to residents in care. Medications were reviewed for accuracy. First aid kit was observed to have adequate supplies and accessible to staff. The facility maintains for each resident Centrally Stored Medication, Destruction Record and PRN Log. LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed facility to have sufficient equipment and supplies to meet activity program needs of residents in care. Note: LPA Villanueva was unable to open the CARE Tools during this visit. Per California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D). {Con't to LIC809-C} {Con't from LIC809} The following deficiencies were observed during today’s inspection: · During medication review, LPA observed that the medication administration record for all 6 residents have missing staff signature on the following dates: 1/2/2024 (all day) and 1/3/2024 (morning). · During staff file review, LPA observed that 1 staff did not have a valid health screen report (LIC503). Staff was hired in 2021 and the LIC 503 on file is from 2017. · During resident file review, LPA observed that 1 out of 6 resident in care did not have a TB test done on record prior to admittance to this facility. Assistant administrator, Grant, attempted to obtain the record from previous residence but per Grant, record of TB test was not obtained. However, a recent record of TB test was done and the result was negative. An exit interview was held with Grant Depositar, and a copy of this report and appeal rights were provided to the facility. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. *the state’s words, verbatim · CDSS document, Jan 3, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 10, 2024

87465 Incidental Medical and Dental Care: (a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interview and observation, the licensee did not ensure 6 of 6 residents' medication administration record that staff signatures were absent from 1/2/24 to morning of 1/3/24 which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 3, 2024

Plan of correction: If medication administration record is being utilized, licensee will ensure staff signature are mark on the medication record ensuring medications were given to the correct residents and in the correct time. Licensee to submit a statement of understanding of the CCR 87465(4) to the Department by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(f) · Plan of correction due date: Jan 10, 2024

(f) All personnel...shall be in good health, and...shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. This requirement is not met as evidenced by: Based on record review and interview, licensee did not ensure that 1 of the 8 staff files reviewed had a valid health screen report. This posed a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jan 3, 2024

Plan of correction: Licensee will ensure all personnel have a valid health screen report not more that 6 months prior to or 7 days after employing staff. Licensee to submit recent health screen report of the staff to the Department by the POC due date. Licensee to submit a statement of understanding of the CCR 87411(f) to the Department by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(b)(1) · Plan of correction due date: Jan 10, 2024

87458(b)(1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by: Based on record review and interview, licensee did not ensure 1 of 6 resident had a TB test done prior to acceptance to this facility. This posed a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jan 3, 2024

Plan of correction: Licensee will ensure that TB test is done prior to admitting resident to this facility. Licensee will submit a statement of understanding of the CCR 87458 to the Department by the POC due date.

Type of visit: Required - 1 Year

On 12/27/2023 at 3:05pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct an annual required visit. LPA met with the facility administrator, Aurora Maigue, and assistant administrator, Grant Depositar, and explained the purpose of today’s visit. The facility is currently licensed to serve 6 non-ambulatory elderly residents. The facility is approved for 4 hospice residents and currently cleared for 1 bedridden. Currently, the facility has no hospice residents in care and no oxygen being used. Present during this visit were 6 residents in care with 2 staff on duty. At 3:16pm LPA and the assistant administrator, Grant Depositar, inspected the facility’s physical plant with the administrator including but not limited to the kitchen, dining room, resident bedrooms, resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. The facility is a one-story structure located in a residential neighborhood. There were no bodies of water on the premises. The fireplace in the livingroom is observed to be screened. Outside of the facility was observed to be cleaned and clear of obstructions. Additionally, LPA observed outdoor furniture for residents’ use and covered area for outdoor activities. Entrance, exits and hallways were observed to be clear of obstructions. LPA observed 6 private resident bedrooms with exit to the outside and 3 bathrooms for resident use. Bathrooms were operational and adequately supplied including with grab bars and non-skid flooring. LPA observed beds and bedding supplies were in good condition, adequate lighting was provided, and sufficient storage for the resident's personal belongings. Bed linens, comforters, and bath towels were adequately stocked during the visit. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were locked and not accessible to residents in care. The kitchen was inspected, and sufficient 2-day perishable and 7-day non-perishable food was maintained adequately. Room temperature was maintained in the facility at 73 degrees F. Water temperature in one of the bathroom was measured at 110 degrees F. The fire extinguisher was last serviced on 1/19/2023. Smoke detector/carbon monoxide combination were tested and found to be operable during this visit. Each resident bedroom was observed to have a smoke detector/carbon monoxide installed. Due to insufficient time, this annual will require a continuation visit. The Department will return at a later date to complete the annual inspection. LPA requested copy of the following documents: liability insurance, updated LIC 500 and updated LIC 308. An exit interview was held with Aurora Maigue and Grant Depositar, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Dec 27, 2023