198603545-8-28-2023-28-AS-BTAO-CV63AV-20230828180522

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603545
Report Date: 08/28/2023
Date Signed: 08/28/2023 06:05:26 PM

Document Has Been Signed on 08/28/2023 06:05 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:	PARK VIEW PLACE		FACILITY NUMBER:	198603545
ADMINISTRATOR:	GUSTIN, PATRICIA		FACILITY TYPE:	740
ADDRESS:	1054 PARK VIEW DRIVE		TELEPHONE:	(626) 885-1800
CITY:	COVINA	STATE: CA	ZIP CODE:	91724
CAPACITY:	142	CENSUS: 51	DATE:	08/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:04 AM
MET WITH:	Staff#1		TIME COMPLETED:	03:45 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) Tao conducted an unannounced annual inspection visit to the facility. LPA met with Staff#1, who assisted with the visit. LPA spoke with Staff#2 over the phone. The reason for the inspection was explained. During the visit, LPA conducted staff/resident interviews, used CARE inspection tool, toured the facility, reviewed food supply, reviewed medications and records, and reviewed staff/residents’ records. Facility fees were current. Interim administrator's administrator certificate was current and had the expiration date on 6/22/24. The facility is licensed to serve age range 60 and over, approved for (142) non-ambulatory, including eight (8) may be bedridden. Delayed egress was approved. The facility had approved hospice waiver for twelve (12) for residents residing in bedrooms# 101,102,103,104,121,122,123, and 124. The building is a three-story building which was consisted of the front lobby, the memory care unit, common areas, resident rooms and private bathrooms, public bathrooms, dining rooms, central restaurant style kitchen, offices, housekeeping closets, activity rooms, bar area, beauty salon, theater room, laundry and linen storage and supply rooms, and medication rooms. The memory care unit is located on the first floor. A delayed egress door system was operational. Alarm system was tested and operational. Signal system was tested and staff arrived within 5 mins. (-continued in LIC 809C-)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

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: PARK VIEW PLACE	FACILITY NUMBER: 198603545
	VISIT DATE: 08/28/2023

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LPA toured the resident rooms #111, 115, 123, 136, 229, 233, and 301. Residents’ bedrooms were observed to have all the required furniture with plenty of personal storage space, linen/supplies, and in compliance. Bathrooms were furnished with grab bars, nonskid surfaces and in compliance.

Hot water temperature was measured in a range of 115.9 to 116.4 degrees Fahrenheit which was within Title 22 Regulation guidelines. The facility had a landline telephone system which was operational and available for resident use. Several fire extinguishers were located and mounted on the walls down each hallway. They were observed to have recent inspections and be fully charged.

Sufficient supply of perishable and non-perishable foods was observed. Refrigerators, freezers, microwaves, ovens, and counter tops were observed to be clean. There were refrigerators located in the assisted living resident bedrooms, and one in the central kitchen. A comfortable temperature of 73 degrees Fahrenheit maintained throughout the entire facility.

Smoke detectors, carbon monoxide detectors and fire extinguishers were located throughout each building. The grounds were properly maintained and there were no hazards observed. No bodies of water observed. The facility also had an electrical and connected fire system that was tested and operational. Last fire drill was conducted on 7/6/23.

All poisons, toxins, and cleaning supplies were locked in the housekeeping closets and were inaccessible to residents in care. First aid kits were inspected and observed the have the required supplies and first aid manual to meet Title 22 Regulations. Staff and resident files will be kept in the director's office on the second floor.

Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview was held. A copy of the report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC809 (FAS) - (06/04)

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