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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 150406240
Report Date: 06/26/2023
Date Signed: 06/26/2023 03:50:51 PM

Document Has Been Signed on 06/26/2023 03:50 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:
06/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:48 PM
MET WITH:Emily WilliamsTIME COMPLETED:
04:09 PM
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On 6/21/2023, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Inspection. LPA conducted facility tour with Emily Williams, Residential Coordinator and Christie Williams, Chief Financial Officer.

Currently, 5 residents are in placement. All residents were at Day Program at time of inspection. Residents attend day program Monday through Friday 8:30 am - 1:30 pm.

Facility tour conducted with Administrator. Facility observed to be well lit, clean and odor free. All common areas have adequate seating available. Resident bedrooms toured, all bedrooms observed to have required furnishings. Bathrooms toured, showers observed to have non-slid mats and grab bars. Kitchen toured, all sharps observed to be locked and secured in lock box. Facility observed to have a 2-day supply of perishable and 7-day of non-perishable available. Medication observed to be locked and secured in medication cart. Medication observed to be administered as ordered. Smoke detectors and carbon monoxide detector observed operational during inspection. Fire extinguisher present with a service date of 9/5/22.

Outside of facility toured. All exits open free of obstruction. Perimeter of back yard is secured with a fence and free of obstruction. Chemicals are locked and secured in supply room.

Exit interview conducted. No deficiencies cited. A copy of this report was provided for facility records.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 06/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2023
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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