306001408-11-2-2022-22-AS-ETAA-CKSPGX-20221102111904

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001408
Report Date: 11/02/2022
Date Signed: 11/02/2022 11:19:13 AM

Document Has Been Signed on 11/02/2022 11:19 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	PARK PLAZA		FACILITY NUMBER:	306001408
ADMINISTRATOR:	BENJAMIN DAVIS		FACILITY TYPE:	740
ADDRESS:	620 S. GLASSELL STREET		TELEPHONE:	(714) 997-5355
CITY:	ORANGE	STATE: CA	ZIP CODE:	92866
CAPACITY:	115	CENSUS: 100	DATE:	11/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Benjamin Davis		TIME COMPLETED:	11:35 AM

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Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with Executive Director Benjamin Davis and stated the purpose of this visit.

The facility is a three-level structure, licensed for seventy-three non-ambulatory residents and thirty-six ambulatory residents with a hospice waiver for eight. Five may be bedridden. This facility offers Residential Care for the Elderly.

At about 9:15 am, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed residents in care and staff members on duty. LPA toured the interior and exterior portions of the facility. The facility has 3 levels. The facility has common areas which include, a dining area, tech room, hair salon, fitness center and a library. Resident rooms were selected at random for inspection. Resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Resident rooms did have private restrooms. Resident restrooms were observed to be in good repair and provided with grab bars and hot water was measured between 111.5 degrees – 118.4 degrees Fahrenheit. LPA also notice handing washing signs throughout the facility. LPA Tapia notice PUB 475 poster posted in a prominent location. Kitchen was in good repair and in a separate room inaccessible to residents. LPA toured the kitchen and saw they had a walk-in refrigerator and freezer. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements. Cleaning supplies and sharp items were inaccessible to residents in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguishers were observed to be charged and operational. Fire alarms and carbon monoxide alarms were previously tested and received a passing score on 05/10/2022.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PARK PLAZA	FACILITY NUMBER: 306001408
	VISIT DATE: 11/02/2022

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For the exterior portion, facility had an outside patio with shaded seating and grounds were free of tripping hazards. The outdoor patio also contained a swimming pool with a locked latched gate surrounding the pool.

LPA Tapia reviewed the COVID 19 mitigation plan and Emergency Disaster plan of the facility.

LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed.

LPA Tapia conducted an exit interview with Executive Director Benjamin Davis and copy of this report was explained and left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022

LIC809 (FAS) - (06/04)

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