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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607752
Report Date: 07/16/2023
Date Signed: 07/16/2023 03:42:24 PM

Document Has Been Signed on 07/16/2023 03:42 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 #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: DATE:
07/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Maria BasaTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility at approximately 10:15 am. LPA Smith was greeted by administrator and disclosed the purpose of the visit. The administrator was contacted and arrived later.

LPA conducted a tour of the physical plant at approximately 11:45 am to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common areas were observed for the ability to safely serve the needs residents. These included the kitchen/dining area and living room. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be furnished appropriately.

LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The
kitchen food supply was observed and sufficient for the two (2) residents currently residing there. Two (2) days of perishable food observed. The freezer is stocked with meats and frozen vegetables. Sharps are stored in locked metal box under kitchen sink. The resident medications and first aid kit stored in a locked kitchen cabinet next to the refrigerator. The medications were observed to be inaccessible to residents. There are two (2) fire extinguishers: one (1) attached to back of kitchen wall next to medication cabinet and one (1) attached to wall at the end of hallway near bathroom #2. Fire extinguishers observed to be charged.

The facility has a total of six (6) bedrooms and two (2) bathrooms. There are four (4) bedrooms for residents and two (2) bedrooms for staff. The resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a supply of linens in bathroom #2 closet.

(Cont to 809C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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 #2
FACILITY NUMBER: 197607752
VISIT DATE: 07/16/2023
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(Cont from 809)

Each bathroom has posted “wash your hands” signs and the following items available: hand soap, paper
towels, and trash cans. The hot water temperature was measured for the two (2) bathrooms to ensure it is
within the required range for residents’ comfort and safety. The water temperature range was between 111.4- and 113.9-degrees Fahrenheit.

Garage: is attached and used to store: one (1) freezer used as food back stock and cabinets used for storage. Laundry room is also in garage. The appliances observed to be functional. Toxins stored in
locked cabinet in garage and observed to be locked and inaccessible to residents.

Frontyard: There is a patio area in front with adequate seating and table observed to be in good repair.
Backyard has the following: Patio area with adequate seating. Patio furniture observed to be in good repair. The is locked shed storing yard tools and PPEs. Shed observed to be locked and inaccessible to residents

There is an in-ground pool in the facility in the backyard. The pool is gated (fenced minimum of 5 ft) and observed to be locked and inaccessible to residents.

Smoke detectors/carbon monoxide detector were tested and operable at time of visit.

Facility grounds were free of hazards. There were no immediate health and safety hazard observed during the day of inspection.

At approximately 12:45 pm, LPA reviewed files for the two (2) residing residents. Resident files included medical assessments, admission agreements, personal rights, individual program plan, and immunization records. Staff files reviewed for all four (4) staff. Staff files had the appropriate trainings to include DSP trainings, and First aid/CPR.

No deficiencies cited.

Exit Interview Conducted / A Copy of the Report Issued

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2023
LIC809 (FAS) - (06/04)
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