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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071440693
Report Date: 05/10/2022
Date Signed: 05/10/2022 02:10:44 PM


Document Has Been Signed on 05/10/2022 02:10 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: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: 5DATE:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Administrator, Janice JosephTIME COMPLETED:
02:20 PM
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On 05/10/2022 at 12:55 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an Infection Control Inspection, LPA was greeted by one staff upon entry and explained the purpose of the visit. The Administrator, Janice Joseph (ADM) was telephoned by the staff member and arrived about 10 minutes later.

Facility has a COVID-19 mitigation plan on file. LPA requested a staff and resident roster from ADM. LPA observed screening station at the entry with COVID-19 signage, a visitor sign-in log, sanitizer, masks gowns, face shields and gloves; an isolation cart is available and a surplus of PPE is centrally stored in the garage. LPA toured the facility including, but not limited to common areas, bathrooms, bedrooms, kitchen, and backyard. LPA observed hand washing and COVID-19 signs posted. There was a sufficient supply of 7-day perishables and 2-day supply of non-perishable foods. All hand washing stations were equipped with soap and covered garbage cans. Residents dispose of paper towels in the toilet, so personal towels are to be kept in their own room. ADM to provide covered garbage cans in shared areas. Hot water temperature in the shared residents' bathroom was measured at 105.2 degrees Fahrenheit (F) and facility temperature was 72 degrees (F). Fire extinguisher last inspected 05/10/2021 and was observed full. Smoke/Carbon Monoxide detectors were observed operational.

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

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: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
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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