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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004478
Report Date: 03/14/2022
Date Signed: 03/14/2022 09:57:26 AM


Document Has Been Signed on 03/14/2022 09:57 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:PRINCEVILLE - COLLEGE PARKFACILITY NUMBER:
306004478
ADMINISTRATOR:MYRIAM OLIVERFACILITY TYPE:
740
ADDRESS:3601 OLEANDER STREETTELEPHONE:
(562) 296-8800
CITY:SEAL BEACHSTATE: CAZIP CODE:
90740
CAPACITY:6CENSUS: 6DATE:
03/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Myriam OliverTIME COMPLETED:
10:05 AM
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit. Administrator (AD) Myriam Oliver was also present and I explained to her the reason for my visit today. LPA observed all required postings on the wall throughout the facility. AD Myriam Oliver has a current administrators certificate that expires on 06/10/2022. LPA observed a screening station near the entrance of the facility with a screening log book, and temperature thermometer for screening clients and visitors. LPA began the tour of the facility with AD Myriam Oliver. As soon as the tour started, Lee Oliver arrived and he lead me around the facility for the rest of the tour. There were six residents in care at the facility. LPA began checking client rooms and bathrooms. Client rooms have the necessary requirements, night stand, chair, lamp and storage space. There was a first aid kit locked in a hallway closet. Bathrooms were operational and clean. In Bathroom #1 LPA measured the water temperature at 109.5 degrees Fahrenheit, bathroom #2: 105.2 degrees Fahrenheit, and in bathroom #3: 105.2 degrees Fahrenheit. The facility had a two day supply of perishable food items and seven days supply of nonperishable food items. The stove was clean and four of five burners were operational. LPA advised the importance of the facility being in good repair at all times. Knives were locked in a closet near the kitchen and more below the sink. Hazardous chemical are locked below the sink. The facility has adequate PPE supply of gloves, N95 mask, surgical mask, and hand sanitizers. LPA toured the backyard and observed both side exit gates of the house were self closing and self latching. LPA observed a shaded area in the backyard equipped with tables and chairs for the residents in care. There were no bodies of water observed. All smoke detectors were tested and are operational. No deficiencies are being cited during todays visit. An exit interview conducted and a copy of the report was provided to the Administrator Myriam Oliver.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
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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