<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 150406240
Report Date: 05/20/2022
Date Signed: 05/20/2022 03:09:33 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/20/2022 03:09 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:PARK HOMEFACILITY NUMBER:
150406240
ADMINISTRATOR:CORNELL, BEVERLYFACILITY TYPE:
735
ADDRESS:14150 SUNSET BLVD.TELEPHONE:
(661) 854-4543
CITY:ARVINSTATE: CAZIP CODE:
93203
CAPACITY: 6CENSUS: 5DATE:
05/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:08 PM
MET WITH:Licensee Beverly Cornell
Administrator Emily Williams 		TIME COMPLETED:
03:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 05/20/22, 2:00 PM, Licensing Program Analyst (LPA) L. Salazar arrived unannounced to conduct an annual inspection. LPA was met by licensee and Administrator and stated purpose of visit. A tour of the facility was conducted. COVID-19 guidelines are in place.

LPA toured the facility inside and out and observed facility to be clean, free from odor without any obstructions or fire clearance issues. LPA observed chemicals and cleaning solutions located in a locked kitchen cabinet. Medications are locked in a tool chest with wheels located in the kitchen. The facility temperature read at 75 degrees. The hot water temperature read at 115 degrees F. LPA observed required postings in the facility.

LPA observed a 4 bedroom 3 bathroom house, three bedrooms are single occupancy and one bedroom that is shared with 2 residents. LPA observed 5 out of 5 residents in care.

LPA observed a 2 day supply of perishables and 7 day supply of non-perishable foods.

Exit interview was conducted. A copy of this report was left with Administrator. No deficiencies observed on todays inspection.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2022
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 1