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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607752
Report Date: 06/24/2022
Date Signed: 06/24/2022 11:03:56 AM

Document Has Been Signed on 06/24/2022 11:03 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:PARK PLACE RESIDENTIAL CARE #2FACILITY NUMBER:
197607752
ADMINISTRATOR:MARIA VOCTORIA ALVIR BASAFACILITY TYPE:
735
ADDRESS:16740 ROMAR STREETTELEPHONE:
(818) 488-1623
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 4CENSUS: 2DATE:
06/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Ronald Basa TIME COMPLETED:
11:20 AM
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At 10:30 a.m. Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to deliver an annual inspection report. On 6/17/22, LPA Ruiz conducted an annual inspection. Due to technical error, this report is a copy of the annual inspection that took place on 6/17/2022.
Upon arrival, LPA was greeted by Administrator Ronald Basa and granted access to the facility. An entrance interview was conducted. The purpose of the visit was explained. Upon entrance LPA observed covid-19 signage posted outside the facility and along the main entrance. LPA observed a visitor’s sign in log, and a thermometer. Hand sanitizer and PPE supplies were readily available. Administrator proceeded to ask LPA infection control questions.
At 10:20 a.m., LPA initiated a physical plant tour. This is a six (6) bedroom two (2) bathroom Adult Residential Facility, four (4) of which are designated for client use. LPA was able to tour the home and did not observe any immediate health and safety concerns. Sufficient PPE supplies were observed. The fire extinguisher was observed in the kitchen area and has a date of purchase of 10/22/2021. Smoke detectors and carbon monoxide monitors were observed to be functional. LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Sharps, cleaning supplies and medications are centrally stored and are kept locked in various kitchen cabinets and drawers. Extra towels and linens were readily available. The backyard is clean, has various covered shaded areas. There is a gated pool on the property, and it is kept locked and inaccessible to clients.

No deficiencies issued during today’s visit. Report was signed and delivered by the Administrator. An exit interview was conducted with the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2022
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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