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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004573
Report Date: 09/13/2023
Date Signed: 09/13/2023 11:05:17 AM

Document Has Been Signed on 09/13/2023 11:05 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, 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: 0DATE:
09/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Melba AllenTIME COMPLETED:
11:20 AM
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On 9/13/23, Licensing Program Analyst (LPA) Tung Truong and CCL staff Rebecca Ornellas arrived at this facility unannounced to conduct an annual inspection visit. Upon arrival, LPA met with caregiver Marita Tumbaga and explained the reason for the visit. Marita 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 3/16/2024. The facility is licensed to serve up to (6) six non-ambulatory residents. There are currently no residents at this facility.

LPA toured the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms; resident bathrooms, garage, 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 required furniture and lighting throughout the facility. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The hot water temperature was measured at 107.6*F which was within the required range of 105-120*F. The temperature inside the facility measured at 76*F which was within the required range of 68-85*F.

LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair. Proof of current liability insurance was observed. A full Care Tool Inspection was completed at facility.

Report continued on 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2023
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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: PARKVIEW GUEST HOME
FACILITY NUMBER: 347004573
VISIT DATE: 09/13/2023
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LPA requested staff files for review. LPA reviewed (2) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews.

The following forms and documents were requested to be submitted within 15 days:
LIC 308 Designation of Administrative Responsibility, LIC 500 Personnel Report, Copy of Administrator Certificate, LIC 610 Emergency Disaster Plan and Proof of Current Liability Insurance.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC809 (FAS) - (06/04)
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