198603660-7-21-2023-28-AS-CWOG-CTWUTC-20230720155142

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603660
Report Date: 07/20/2023
Date Signed: 07/21/2023 08:26:32 AM

Document Has Been Signed on 07/21/2023 08:26 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	PARKER HOMES 2		FACILITY NUMBER:	198603660
ADMINISTRATOR:	SURESH, BEVINAHLLI		FACILITY TYPE:	735
ADDRESS:	2808 BLAKEMAN AVE		TELEPHONE:	(714) 393-6391
CITY:	ROWLAND HEIGHTS	STATE: CA	ZIP CODE:	91748
CAPACITY: 4		CENSUS: 4	DATE:	07/20/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Kevin Van Beek		TIME COMPLETED:	04:15 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) Wong, conducted an announced visit to the facility for purpose of a Pre-licensing evaluation and met with the administrator Kevin Van Beek. An application was submitted to CCLD on 01/18/2023, for change of ownership for an Adult Residential Facility to serve Developmentally Disabled Adults for ages range 18 through 59. The requested capacity is for two (2) ambulatory and two (2) non-ambulatory. During today's visit, LPA Wong utilized the Compliance and Regulatory Enforcement (CARE) tools for the pre-licensing visit today : 1. Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes dining area, living room, kitchen, laundry area, three clients bedrooms, two clients bathrooms and a detached garage. The passageway, walkway and a patio is free from obstruction. For clients bedrooms, there shall be no more than two clients per bedroom. Bedroom#1 and #2 has one bed, one chair, one drawer, night stand, and sufficient lighting and closet space. Bedroom#3 has two beds, two drawers, two night stands, chair, and sufficient lighting and closet space. Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in hallway cabinet and the extra personal hygiene products are stored under the sink of Bathroom#2. All the bathrooms have a working toilet, bath/tub and shower. Bathroom#2 is accommodate for non-ambulatory client. The hot water temperature in both bathrooms were tested between 114 and 116.7 degrees F. which is within Tittle 22 regulation. All the post are posted and reviewed on the wall near the laundry area. The facility also has a land line telephone system. The smoke detectors are interconnected and located in each bedroom and common area and they are working probably. The carbon monoxide detectors are located near the staff desk in the living room and working well. All the appliances in the kitchen and living room are working probably. All the chemicals and cleaning supplies are stored under the sink and garage and they are all inaccessible to clients. (See LIC809C for continuation)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PARKER HOMES 2	FACILITY NUMBER: 198603660
	VISIT DATE: 07/20/2023

NARRATIVE

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2. Operational Requirement: The fire clearance was approved for two (2) ambulatory and two (2) non-ambulatory and Bedroom#1 and #2 are for ambulatory and Bedroom#3 for 2 non-ambulatory. The facility weekly menu posted next to the refrigerator. The facility has a shaded patio area with table and chairs for client to use for outdoor activity. All the recreational materials are also stored near the patio area. The Applicant will be handling cash resources of clients and has a surety bond for $4000, cash resources will be locked and stored with P & I Ledger in the file cabinet in the living room, accessible to designated staff.

3. Personnel Record-Training: All staff files are maintained and stored in the facility and located in the file cabinet in the living room. When the administrator is absent and it will be a designated staff to cover administrator responsibility. The LIC308 was also completed. The administrator will also ensure all staff are criminal background check cleared.

4. Client Record-Incident Reports: All clients files are maintained and stored in the facility and located at the file cabinet in the living room. The incident reports will be kept in client's files as well.

5.Client's Right and Information: The facility will ensure each client has their personal right to be accorded safe, healthful and comfortable accommodations.

6.Food Service: The adequate food supply are stored in the refrigerator and kitchen cabinet which include the 2 days perishable and 7 days non-perishable food. Additional food storage are stored in the garage. Each refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. Dishes, cups and flat ware are stored in the kitchen cabinets, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored and locked in the kitchen cabinet.

7. Health Related Services: A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in the medication file cabinet, available for staff use but inaccessible to clients. The medication are centrally stored in the medication file cabinet next to the kitchen and they are inaccessible to the clients.

8. Disaster Preparedness: The facility has an updated emergency disaster plan dated on 4/11/23 posted on the wall near the laundry area and has at least two alternative temporary shelter location.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PARKER HOMES 2	FACILITY NUMBER: 198603660
	VISIT DATE: 07/20/2023

NARRATIVE

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Component III
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

During the Pre-Licensing Visit, LPA did not observe anything needs to be corrected. Pre-Licensing Visit Completed.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC809 (FAS) - (06/04)

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