198603425-1-29-2021-28-AS-LMAZ-BXR2FF-20210129162128

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603425
Report Date: 01/28/2021
Date Signed: 01/29/2021 04:21:45 PM

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:	OAK PARK MANOR, LP		FACILITY NUMBER:	198603425
ADMINISTRATOR:	PAOLI, FREDERICK		FACILITY TYPE:	740
ADDRESS:	501 SOUTH COLLEGE AVENUE		TELEPHONE:	(909) 626-0117
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	68	CENSUS: 27	DATE:	01/28/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Applicant, Robert Willis		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Linda Almaraz conducted a pre licensing tele-visit at Oak Park Manor due to a change in ownership. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, this pre-licensing visit was conducted telephonically via Facetime with Applicant Robert Willis, Administrator Frederick Paoli, former Administrator Jennifer Lievfield, Assistance Administrator Donell Clark, Tracy Brown from Quality Care Asset Management and Michael Haden from Sunwest Bank. There are currently 27 residents living in the facility. The fire clearance for Oak Park Manor was granted on 1/20/2021. The fire clearance has been approved for 40 bedridden residents with a total capacity of 68. The physical plant was toured and the following was observed. As part of the Pre-licensing inspection LPA toured the entire facility, inside and out. The facility consists of one large building with three wings and one small house adjacent to the facility. The inspection consisted of 32 resident bedrooms, bathrooms, kitchen, dining area, activity room, medication room, and indoor/outdoor activity areas. The bathrooms are clean and operational with grab bars and non-skid surface/mats in place. The hot water temperature tested at 118.4 degrees Fahrenheit. LPA observed an adequate food supply consisting of at least 2 days of perishables and 7 days of non-perishables. The kitchen appeared to be within Title 22 Regulations. All storage areas for cleaning solutions, toxins, knives, and hazardous items are in secured cabinets and closets and inaccessible to residents. The facility has central air and heating accommodations. All exits doors are equipped with a delayed egress alarm system. The smoke alarms are hardwired/interconnected and appear to be operational. Carbon monoxide detectors are battery operated and appear to be operational. The small home (Cottage), adjacent to the facility, consisted of 4 bedrooms, kitchen and two bathrooms. The unit is currently not being used. LPA will confirm with Fire Department if the Cottage was also inspected and cleared. *Continued on LIC 809-C*

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2021

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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: OAK PARK MANOR, LP	FACILITY NUMBER: 198603425
	VISIT DATE: 01/28/2021

NARRATIVE

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Component III: Conducted at the Pre-Licensing visit.

LPA observed that the facility does not meet Title 22 Regulations. The following are corrections needed by 2/4/21. LPA will conduct a follow up tele-visit to ensure all corrections are made.

· Please ensure all rooms have a mattress pad on the bed even if the bed is vacant.
· Foldable chairs in each room move dinning chairs back to dinning room to make space for residents to walk in their room safely.
· First Aid Manual (Not Guide).
· Trash Can Covers on rooms #2,5,13,24, and 30.
· Trash Can for #31
· CCL “Let Us No" Poster to be posted in common areas.
· Corrected Facility Sketch to include Cottage and correct room numbers.
· Operable closet door (Left) in Room #26.

Cottage House
· Room #2 – Operable alarm on the exit door towards the outside.

LPA will confirm Fire Clearance for Cottage with the Fire Department prior to the next tele-visit.

Exit interview was conducted telephonically with Administrator Frederick Paoli and Applicant Robert Willis. A copy of this report was sent via email for a signature.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2021

LIC809 (FAS) - (06/04)

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