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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001408
Report Date: 12/14/2024
Date Signed: 12/14/2024 05:27:28 PM

Document Has Been Signed on 12/14/2024 05:27 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:PARK PLAZAFACILITY NUMBER:
306001408
ADMINISTRATOR/
DIRECTOR:		BENJAMIN DAVISFACILITY TYPE:
740
ADDRESS:620 S. GLASSELL STREETTELEPHONE:
(714) 997-5355
CITY:ORANGESTATE: CAZIP CODE:
92866
CAPACITY: 115CENSUS: 86DATE:
12/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:24 AM
MET WITH:Debbie Marroquin/RRDTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 12/14/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Debbie Marroquin/RRD. LPA explained the purpose of today’s visit. The facility is licensed to serve (115) elderly adults ages 60 and above, of which (73) can be non-ambulatory and (5) Bedridden on 1st and 2nd floor. The facility has an approved hospice waiver for (8).

The facility is located on a residential neighborhood it consists of a three level structure, The facility has common areas which include, a dining area, tech room, hair salon, fitness center and a library.



LPA Iniguez and the Administrator toured the physical plant. There was a gated pool at the premises. No obstructions on the premises. LPA inspected a total of (7) bedrooms and (7) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 115.6°F to 117.4°F, and the room temperature ranged from 76°F to 78°F.

The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PARK PLAZA
FACILITY NUMBER: 306001408
VISIT DATE: 12/14/2024
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During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 10/17/24.

A review of (5) residents' service files and (4) staff personnel files was performed. LPA reviewed (3) Medication Administration Records (MARs) and found no discrepancies.

LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance was provide to LPA. Facility Annual Fees are not current, LPA provided notice to administrator regarding fees.

Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below:

-See D page for details.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. *


An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Debbie Marroquin / RRD.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/14/2024 05:27 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 12/14/2024 at 01:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PARK PLAZA
FACILITY NUMBER: 306001408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in not having a TB test on file for two staff members on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2024
Plan of Correction
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Licensee will ensure all facility staff has a TB test on file at all times. As plan of correction, licensee will provide missing TB tests from staff to LPA via email before poc due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/14/2024 05:27 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 12/14/2024 at 01:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PARK PLAZA
FACILITY NUMBER: 306001408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in not having a health screening on file for 2 staff members which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2024
Plan of Correction
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3
4
Licensee will ensure all facility staff has a health screening on file at all times. As plan of correction, licensee will provide proof of health screening to LPA via email before poc due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2024


LIC809 (FAS) - (06/04)
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