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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001408
Report Date: 12/16/2021
Date Signed: 12/16/2021 11:34:29 AM

COMPREHENSIVE INSPECTION
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:PARK PLAZAFACILITY NUMBER:
306001408
ADMINISTRATOR:BENJAMIN DAVISFACILITY TYPE:
740
ADDRESS:620 S. GLASSELL STREETTELEPHONE:
(714) 997-5355
CITY:ORANGESTATE: CAZIP CODE:
92866
CAPACITY:115CENSUS: 89DATE:
12/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Ben DavisTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Michelle Reed made an unannounced visit to the facility to conduct an Annual visit. Upon arrival LPA met with Administrator Benjamin Davis. The focus of the visit was Infection Control. LPA toured the facility with Mr. Davis and the following was observed:
Covid signs were posted at the front entrance of facility with a sanitization station. LPA's temperature was taken upon arrival and an electronic sign in sheet(Accushield) was available. Facility has required Department postings throughout the facility. Administrator Certificate for Benjamin Davis expires on 12/12/2022. LPA toured the hallways as well as the dining room. Hand sanitizing stations were present throughout the building. Sanitizing stations will also be placed outside the elevators and staff break room. Restrooms contained soap, paper towels and toilet paper. Hand sanitizer, soap, wipes and gloves were present and in sufficient supply. The Licensee has at least a 30 day supply of PPE. LPA observed an outside visitation area with ample shading. Residents were socializing in the lobby. Social Distancing and masks were observed. Licensee has required Mitigation plan and Emergency Disaster Plan. Facility has emergency food and water supply. Facility has a secured medication room for resident medication and files. All residents have at least a 30 day supply. Covid Testing is done on a weekly rotation basis on Monday and Thursday.

During the visit, LPA consulted with Administrator regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA advised the importance of mask wearing and handwashing for staff. Administrator is reminded to review PINS in regards to Visitation, dining, Group Activities, Non-essential services, Outings, New Admissions and Entertainment. as well as updated Facility Staff Testing and Masking Guidelines. No deficiencies noted during visit. An exit interview was conducted and a copy of this report was provided to Ben Davis.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
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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