197606329-12-19-2023-31-AS-MCAA-CYNU7Y-20231219142042

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606329
Report Date: 12/19/2023
Date Signed: 12/19/2023 02:21:24 PM

Document Has Been Signed on 12/19/2023 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	PARK PLACE RESIDENTIAL CARE		FACILITY NUMBER:	197606329
ADMINISTRATOR:	MARIA ALVIR		FACILITY TYPE:	735
ADDRESS:	10401 DENSMORE AVENUE		TELEPHONE:	(818) 920-1084
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY: 6		CENSUS: 6	DATE:	12/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:33 AM
MET WITH:	Jane Militante		TIME COMPLETED:	02:30 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	Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff, Jane Militante and explained the reason for the visit. Administrator, Ron Basa joined shortly after. The home is a level 3 Adult Residential Facility (ARF). At approximately 10:40am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms and carbon monoxide detectors are battery operated. The fire extinguisher is located in the kitchen. It was purchased on 12/11/23. The emergency, earthquake and fire drills were last conducted September 10, 2023. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. No knives and cleaning supplies were observed to be accessible. They were locked. Bedrooms: There were three (3) bedrooms designated for residents' use. All three bedrooms are shared rooms. All three bedrooms in use by residents were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 110 degrees Fahrenheit. There were no cleaning supplies observed in the bathrooms. Common Areas: These included the living room and dining room area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PARK PLACE RESIDENTIAL CARE	FACILITY NUMBER: 197606329
	VISIT DATE: 12/19/2023

NARRATIVE

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Surrounding Grounds: Entry/exits were free of obstruction. There was sufficient space in the backyard to hold outdoor activities. There are two storage spaces in the backyard. LPA observed these storage spaces to hold extra supplies and unused beds and wheelchairs. Both storage spaces were locked, requiring a key to gain access. The front and backyards were free of hazards.

Garage: The garage is also used as extra storage space and laundry room. Cleaning supplies and detergents are maintained in the garage. There is also a corner office for staff. The garage is always locked. It requires a code to unlock and gain entry.

Resident Files: Resident files are kept in a cabinet located in the living room area. LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: Staff files are also kept in the cabinet located in the living room area. LPA conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: The medication cabinet is kept in the kitchen. It was observed locked. Medications and Medication Records were review for proper storage and documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC809 (FAS) - (06/04)

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