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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071440693
Report Date: 04/25/2024
Date Signed: 05/07/2024 04:52:46 PM


Document Has Been Signed on 05/07/2024 04:52 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: 3DATE:
04/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Janice Joseph, AdministratorTIME COMPLETED:
02:45 PM
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On 04/25/24 around 10:45 AM, L. Holmes, Licensing Program Analyst (LPA) arrived unannounced for a required annual inspection. LPA met with Janice Joseph, Administrator (ADM), and explained the purpose of the visit. LPA toured the facility with ADM who currently holds a certificate (#6025466740) that expires 03/15/25; The facility’s fire clearance was approved for six (6) non-ambulatory residents; all six (6) may be non-ambulatory and one (1) may be hospice.

Upon arrival LPA observed one (1) staff attending to one (1) resident that was watching television. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of five (5) total bedrooms. All outdoor and indoor passageways are free of obstruction. The body of water is enclosed. A comfortable temperature was maintained at 70 degrees Fahrenheit (F). LPA observed lighting in all rooms to be adequate for the comfort and safety of the residents. The hot water temperature was measured at 114.5 degrees (F). All toilets, hand washing, and bathing areas were safe, sanitary and in operating condition. All hand washing stations were stocked with hand-washing soap and hand drying supplies. Linen and hygiene products were available for all residents. PPE, sanitizer, and paper goods were sufficient.

...continued on LIC809C.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 10


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 071440693
VISIT DATE: 04/25/2024
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...continued from LIC809

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last inspected on 05/12/2e and observed full. Emergency Disaster Plan is posted. First aid kit was complete and emergency kits for each resident are available. Fire drills remain conducted quarterly.

Three (3) Staff records were reviewed, and all staff have criminal record clearance. All three (3) residents' records reviewed were current and complete.

The following forms are to be updated and submitted to CCLD:
-Resident roster
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC610D Emergency Disaster Plan
-Update staffs files with first aid/CPR certification
-Update staffs annual training records

No deficiencies cited during visit.
Exit interview conducted and a copy of this report provided to ADM.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 10