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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071440693
Report Date: 05/13/2025
Date Signed: 05/13/2025 03:01:10 PM

Document Has Been Signed on 05/13/2025 03:01 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/
DIRECTOR:		JOSEPH, JANICEFACILITY TYPE:
740
ADDRESS:4901 PLAZA WAYTELEPHONE:
(510) 233-3240
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
05/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Janice Joseph, Administrator
Nicole Joseph, Co-Administrator 		TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 05/13/25 around 12:00 PM, L. Holmes, Licensing Program Analyst (LPA) arrived unannounced for a required annual inspection. LPA met with Janice Joseph, Administrator (ADM) and Nicole Joseph, Co-Administrator, and explained the purpose of the visit. 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) resident was lounging in the front yard and another watching television and having lunch. 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 were free of obstruction. The body of water is enclosed and secured. A comfortable temperature was maintained at 71 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 113.5 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.
Yvonne Flores-LariosTELEPHONE: (510) 286-0517
Lisha HolmesTELEPHONE: 510-286-4201
DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 05/13/2025
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...continued from LIC809

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last inspected on 12/20/24 and observed full. Emergency Disaster Plan is posted. First aid kit was complete and emergency kits for each resident are available. Fire drills are 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 by 05/27/25:
-Resident roster (Reviewed)
-LIC500 Personnel Report (Reviewed)
-LIC308 Designation of Administrative Responsibility (Reviewed)
-LIC610E Emergency Disaster Plan; change to LIC610D


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

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC809 (FAS) - (06/04)
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