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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071440693
Report Date: 06/03/2020
Date Signed: 06/03/2020 12:55:14 PM

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:PARK PLAZA REST HOMEFACILITY NUMBER:
071440693
ADMINISTRATOR:JOSEPH, JANICEFACILITY TYPE:
740
ADDRESS:4901 PLAZA WAYTELEPHONE:
(510) 233-3240
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY:6CENSUS: 4DATE:
06/03/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Janice Joseph, AdministratorTIME COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Praveen Singh conducted an unannounced Case Management health and safety tele-inspection with Administrator in relation to information received by the Department. This inspection was conducted via video-conference due to the present shelter in place order by the Governor.

During the tele-inspection, LPA toured the facility, including but not limited to the kitchen, dining room, garage, living space, and outside areas. LPA observed a sufficient supply of perishable and non-perishable foods. LPA observed locked drawers and cabinets for sharps, cleaning supplies and medications. LPA observed passageways appeared to be free of obstruction. LPA was informed by Administrator that everything was in good repair and no disruption to utilities.

LPA was informed that R1 was awaiting Covid-19 test results and that an incident report would be submitted to CCL no later than 6/5/2020.

No deficiencies cited during inspection. Exit interview conducted and a copy of the report emailed to Administrator.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2020
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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