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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 150406240
Report Date: 05/25/2024
Date Signed: 05/25/2024 02:21:55 PM

Document Has Been Signed on 05/25/2024 02:21 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/
DIRECTOR:		CORNELL, BEVERLYFACILITY TYPE:
735
ADDRESS:14150 SUNSET BLVD.TELEPHONE:
(661) 854-4543
CITY:ARVINSTATE: CAZIP CODE:
93203
CAPACITY: 6CENSUS: 5DATE:
05/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:26 AM
MET WITH:Beverly Cornell
Emily Williams
TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 5/25/2024, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Inspection. LPA arrived, introduced self, and allowed entrance by House Manager, Emily Williams. Licensee, Beverly Cornell was also present during today's inspection.

Facility tour was conducted with House Manager. Facility observed to be clean, odor free, and be well lit. Resident bedrooms observed to have all required furnishings. Facility has adequate additional linen available for all residents Resident bathrooms toured, water temperature measured at 117 degrees F. Kitchen toured, facility has a 2-day supply of perishable and a 7-day supply of non-perishable food available for residents. All knives observed to be locked and secured in medication cart. Medication was observed to be locked and secured in medication. All medication observed to have original labels and be administered as prescribed.

All chemicals, additional refrigerators and freezers observed to be locked and secured in supply room. Fire extinguishers present and observed to have a service 10/26/23. Carbon monoxide and smoke detectors observed to be operational during today's inspection. Last fire drill was 5/21/24 according to facility records.

Outside of facility toured. All exits open free of obstruction. No hazards observed.

LPA requested the following documents be submitted to Fresno Regional Office no later than 6/7/2024: LIC 309 Administrative Organization, LIC 500 (Personnel Report), LIC 610 (Emergency Disaster Plan), Surety Bond, and Current Administrative Certificate.

No deficiencies cited during inspection.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2024
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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