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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607752
Report Date: 08/24/2025
Date Signed: 08/24/2025 12:25:12 PM

Document Has Been Signed on 08/24/2025 12:25 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: 3DATE:
08/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:32 AM
MET WITH:Cameron Basa, Staff/AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility at 08:35 am. LPA observed front yard and grounds which were clean and clear of hazards. LPA was greeted by staff and disclosed the purpose of the visit. The administrator Maria Basa was contacted and arrived later.
LPA conducted a tour of the physical plant at approximately 08:55 am to ensure there are no health and safety hazards, and the facility is following Title 22 Regulations. Common areas—including the combined living and dining room, as well as the kitchen were evaluated for their ability to safely meet resident needs. The common areas were found to be clean, sanitary, and furnished with seating sufficient to comfortably accommodate the residents in care.
LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the three (3) residents currently residing there. Two(2) days of perishable food observed.The freezer is stocked with frozen foods to include a variety of meat/poultry and vegetables. Sharps are stored in a locked metal box under the kitchen sink. The resident medications and a fully stocked first aid kit are 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) wall mounted fire extinguishers: one (1) in the kitchen next to the medication cabinet and one (1) at the end of hallway near bathroom #2. Fire extinguishers observed to be charged.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Tihesha Smith
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 08/24/2025
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The facility has a total of six (6) bedrooms/two (2) bathrooms. Four (4) bedrooms for residents and two (2) bedrooms for staff. The residents’ 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. Supply of linens in 2nd bathroom closet. A free standing cabinet in the 2nd bathroom stores incontinence supplies. Each bathroom has the following: hand soap, paper towels, and trash cans. The water temperature range was between 110.0- 120 degrees Fahrenheit.

The laundry room is in the garage and the appliances were observed to be functional. Toxins are also stored in locked cabinets in the garage and observed to be inaccessible to residents. Garage is attached with locked entry through kitchen. Garage is storage for: additional refrigerator/freezer used for excess foods and cabinet used as pantry to store canned goods/dry foods. Front yard: There is a patio area in front with adequate seating and table.
Backyard has the following: Two Patio areas with adequate seating. All patio furniture observed to be in good repair. There is a locked shed on the side of the house used to store additional PPEs, tools and equipment. Shed observed to be 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. Carbon monoxide and smoke detectors were tested and operable at the time of visit. Facility grounds were free of hazards.

LPA reviewed facility files to include four (4) staff records and three (3) resident files at approximately 09:15 am. The staff records included current administrator certificates, current CPI (Crisis Prevention & Intervention cards) and fingerprint clearances. Resident files included admission agreements, personal rights, and current individual program plans. LPA interviewed newly certified staff with administrators license at 12:15 pm.

There were no immediate health and safety hazards observed during the day of inspection. No deficiencies cited.

Exit Interview Conducted / A Copy of report given
NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Tihesha Smith
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2025
LIC809 (FAS) - (06/04)
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