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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801595
Report Date: 10/07/2023
Date Signed: 10/07/2023 04:25:52 PM


Document Has Been Signed on 10/07/2023 04:25 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:PARKVIEW VILLAGE IIFACILITY NUMBER:
405801595
ADMINISTRATOR:I.PATACSIL & C. PATACSILFACILITY TYPE:
740
ADDRESS:1577 BADEN AVE.TELEPHONE:
(805) 474-9030
CITY:GROVER BEACHSTATE: CAZIP CODE:
93433
CAPACITY:6CENSUS: 5DATE:
10/07/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:I Enos Patacsil, AdministratorTIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) conducted a case management annual continuation of the facility. LPA met with Administrator I Enos Patacsil and explained the purpose of the visit.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 5 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, LIC. 602A Physicians report, Pre-appraisals, Appraisals Needs and Services Plan, Emergency and ID forms, all forms were legible and completed in separate confidential folders for each resident in care.


Incidental Medical Services: Facility provides transportation or assist in providing transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed all 5 residents medications, no labels were altered, and no medications were expired. All forms were completed accurately.
Administrator and 1 staff person review medications for destruction, complete forms and take to the pharmacy to be destroyed.

Exit interview conducted and copy of report printed for Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2023
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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