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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601054
Report Date: 04/04/2022
Date Signed: 04/04/2022 02:39:36 PM

Document Has Been Signed on 04/04/2022 02:39 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PARKVIEW MANORFACILITY NUMBER:
198601054
ADMINISTRATOR:CHERTOK, VLADAMIRFACILITY TYPE:
735
ADDRESS:5055 NOVGOROD STREETTELEPHONE:
(323) 225-4293
CITY:LOS ANGELESSTATE: CAZIP CODE:
90032
CAPACITY: 86CENSUS: 74DATE:
04/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Elena Novikova, AdministratorTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit to issue a citation for potential hazardous items observed during the complaint visit control #28-AS-20220401135020.

LPA toured the facility with the Administrator at 11:30am and observed wooden boards with nails, tools behind trailers, and 2 metal rods in front of building "E" grounds. These were observed to be potential health and safety risks for clients in care as these items can be used as weapons.

Based on observation, the deficiency is issued on the LIC809D in accordance to the Title 22 Regulations.
An exit interview was conducted and a copy of this report, LIC809D, and appeal rights were given to the Administrator.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2022
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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Document Has Been Signed on 04/04/2022 02:39 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 04/04/2022 at 01:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PARKVIEW MANOR
FACILITY NUMBER: 198601054

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/18/2022
Section Cited
CCR
80087(c)

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80087 Buildings and Grounds (c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.
This requirement is not met as evidenced by:
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The licensee shall keep all open areas free of obstruction. The proof of correction shall be provided to LPA by POC due date 4/18/22.
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Based on observation, the licensee did not ensure that the open area behind the trailers and in front of building E are cleared of obstruction which is a potential health and safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2022


LIC809 (FAS) - (06/04)
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