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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802269
Report Date: 12/19/2023
Date Signed: 12/19/2023 11:49:19 AM


Document Has Been Signed on 12/19/2023 11:49 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:PARK GROVE, THEFACILITY NUMBER:
405802269
ADMINISTRATOR:MARCOS, SISENANDO M JRFACILITY TYPE:
740
ADDRESS:338 MARGARITA AVETELEPHONE:
(805) 541-1772
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:6CENSUS: 4DATE:
12/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator - Sisenando MarcosTIME COMPLETED:
11:46 AM
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 At 9:05am on 12/19/2023, Licensing Program Analyst(LPA) Jeffries arrived unannounced to the facility to conduct the annual facility inspection. LPA met with Administrator's Sisenando and Susan Marcos announced who he is and the reason for the visit.

LPA conducted a full facility tour. LPA noted that this is a 8 bedroom and 4 bathroom There are 6 resident rooms and two staff rooms. Three of the 4 bathrooms are resident bathrooms and one bathroom is designated for staff. LPA observed at least two days of perishable and at least seven days of non perishable foods on hand in the facility, There is emergency water and food stored in the garage. This facility has a full use generator on the property. LPA noted that there are smoke detectors located throughout the facility that are hardwired and functional, LPA noted that the carbon monoxide detector is located in the hallway and is functioning properly. LPA noted the two fire extinguishers on hand are currently tagged and in the green. The facility has a fire sprinkler system that was pressure certified on 01/10/2023 by Mid-Coast Fire Protection and will be reinspected in January of 2024. LPA noted that all rooms had exit doors and all passageways and doors were free and clear of obstructions. LPA noted that the facility is clean and in good repair. LPA conducted a sample medication audit and reviewed the centrally stored medication record (CSMR). LPA reviewed staff and resident files. LPA noted that resident rooms have proper lighting storage and linins. LPA noted that the water temperature in the facility is within regulation parameters of 105*-120*(f). LPA noted that during the full inspection of the facility and facility grounds there were not violations or citations.

Administrators and LPA conducted a full review of the annual care tools modules. LPA noted that there were no technical, violations, or citations issued as a result of the full care tools review. LPA noted that there are no citations issued as a result the this annual inspection.

Exit interview, report read, and report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023
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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