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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004573
Report Date: 09/21/2022
Date Signed: 09/21/2022 03:06:41 PM


Document Has Been Signed on 09/21/2022 03:06 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:PARKVIEW GUEST HOMEFACILITY NUMBER:
347004573
ADMINISTRATOR:ALLEN, DREW S.FACILITY TYPE:
740
ADDRESS:10390 JILLSON WAYTELEPHONE:
(916) 685-6129
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:6CENSUS: 2DATE:
09/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Melba AllenTIME COMPLETED:
03:15 PM
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On 09/21/2022 at 1:25 AM, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection visit. Upon LPAs arrival, Caregiver Marita Tumbaga was present at facility and contacted Co-Administrator, Melba Allen who arrived a bit later. LPA met with Co-Administrator Melba Allen and explained the purpose of the visit.

Administrator holds current certification #6001867740 and expires on 3/16/2022. The facility is licensed to serve up to (6) six non-ambulatory residents. There are 2 residents who reside at this facility. LPA toured the facility with Co-Administrator Melba Allen on 09/21/2022 at 2:10 pm.

LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms; resident bathrooms, laundry area, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. The hot water temperature was observed to be 112.0 degrees Fahrenheit. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed knives and toxins to be locked away and inaccessible to residents. Smoke and carbon detectors were in good repair. Fire extinguisher and first aid kit were up to date. LPA checked medication storage and found medication to be locked away and inaccessible to clients. LPA also conducted the infection control domain tool.

Report continued on 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: PARKVIEW GUEST HOME
FACILITY NUMBER: 347004573
VISIT DATE: 09/21/2022
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The facility mitigation plan was submitted to CCLD, and it was approved on 5/04/2021. Facility has routine symptom screening checks for residents, staff, and visitors. The facility has a symptom check binder for staff, residents, and care staff. Hand Hygiene procedures have been implemented. Facility had Covid-19 posters throughout the facility, and the facility has implemented Covid-19 mitigation plan.

Administrator was informed to send updated copies of the following documents to CCL within 15 days:
(1) LIC308 Designation of Administrative Responsibility
(2) LIC500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance
(6) LIC309 Administrative Organization

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit.

Exit interview held with Co-Administrator Melba Allen and a copy of report given at the conclusion of the visit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2