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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607752
Report Date: 06/17/2024
Date Signed: 06/17/2024 12:54:56 PM

Document Has Been Signed on 06/17/2024 12:54 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/
DIRECTOR:		MARIA VOCTORIA ALVIR BASAFACILITY TYPE:
735
ADDRESS:16740 ROMAR STREETTELEPHONE:
(818) 488-1623
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 4CENSUS: 2DATE:
06/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:25 AM
MET WITH:Maria BasaTIME VISIT/
INSPECTION COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility at approximately 10:25 am. LPA Smith was greeted by administrator and disclosed the purpose of the visit.

LPA conducted a tour of the physical plant at approximately 10:40 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 toxins stored/locked in garage. 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 2nd bathroom closet. Standalone cabinet in 2nd bathroom stores incontinence supplies.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2024
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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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: 06/17/2024
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Cont. from 809)

Each bathroom 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 109.4- and 113.9-degrees Fahrenheit.

Garage: is attached and used to store: one Refrigerator/freezer used for excess foods and cabinet used as pantry to store canned goods/dry foods. 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.

Front yard: There is a patio area in front with adequate seating and table observed to be in good repair.
Backyard has the following: Two Patio areas with adequate seating. Patio furniture observed to be in good repair. There is a shed on side of house to store: Additional PPEs, tools and equipment. 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 11:05 pm, LPA reviewed files for the two (2) residing residents. Resident files admission agreements, personal rights, individual program plan and centrally stored medication. Staff files reviewed: four (4) staff files had current First aid/CPR, fingerprint clearances, administrators’ certificate.

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: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC809 (FAS) - (06/04)
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