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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 150406240
Report Date: 06/28/2021
Date Signed: 06/30/2021 08:40:45 AM

Document Has Been Signed on 06/30/2021 08:40 AM - 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:
06/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Administrator Christine WilliamsTIME COMPLETED:
04:30 PM
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Licensing Program Analyst LPA Shawna Doucette conducted an Annual Inspection on this date. LPA was met by Administrator Christine Williams and discussed the purpose of the visit. LPA and Administrator began the tour at the front entrance of the facility.

Visitor log-in/temperature check, masks, and disinfection station was observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common areas. Hand washing and other various Covid-19 related signs were observed in the common areas.

LPA observed a two day supply of perishable food and seven day supply of non-perishable food. Cleaning supplies were observed behind a locked cabinet. LPA observed the following personal protective equipment in a storage cabinet; hand sanitizer, gown, face shield, gloves, and masks. Staff records were reviewed for infection control training. Resident’s files have updated emergency contact information.

No deficiencies were observed.

Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2021
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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