405850052-3-15-2021-29-AS-RDLN-BZ5VJS-20210315162913

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850052
Report Date: 03/15/2021
Date Signed: 03/15/2021 04:30:19 PM

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 PLACE ASSISTED LIVING		FACILITY NUMBER:	405850052
ADMINISTRATOR:	BARNHILL, DIANA		FACILITY TYPE:	740
ADDRESS:	7500 PORTOLA RD		TELEPHONE:	(805) 591-9855
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY:	12	CENSUS: 12	DATE:	03/15/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Diana Barnhill		TIME COMPLETED:	03:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Rachael De Leon conducted an announced pre-licensing visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s pre-licensing visit was conducted via Facetime with Diana Barnhill Licensee/Administrator. Plant Tour: LPA took a virtual plant tour through-out the inside and outside of the facility. A fire clearance was approved for capacity of 12 Non-ambulatory residents. The facility has a living room, dining room, kitchen, bedrooms, bathrooms, staff office, basement The home has smoke detectors in each room, carbon monoxide detectors in the hallway and sprinkler system through-out. The common areas were furnished adequately at this time. The lighting was adequate throughout the facility. Medications will be stored in a locked medication closet in office area. Each exit is alarmed throughout the facility. All required documents and signs were posted in the facility. The facility is equipped with a large generator for back up power. Resident Rooms: Bedroom furnishings and lighting in all rooms is adequate. The Facility provides extra linens to change beds at least every week or as needed. Each room has a closet.. Bathrooms: Rest rooms are clean, sanitary and in operating condition with grab bars for the toilets and tub. The tubs/and showers have non-skid mats. Licensee test the water and it measured at 110 degrees Fahrenheit. Kitchen: Kitchen has locked drawer to store knives and other sharps. Kitchen has all appliances and all were in operable condition. The facility has 1 week of non-perishables and 2 days of non-perishables, plus additional food as well as emergency food supplies and water.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2021

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PARK PLACE ASSISTED LIVING	FACILITY NUMBER: 405850052
	VISIT DATE: 03/15/2021

NARRATIVE

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Office: Resident and staff records are stored in locked filing cabinets and office.

Laundry Room: All supplies are kept locked for housekeeping, working washer and dryer were present.

Basement: Has a locked gate to get down stairs, staff have access to keys, additional supplies for hygiene/grooming, food, emergency food, PPE supplies, and cleaning products, all keep separately on shelving.

Outside back/side Yards: The exterior passageways were clean and clear of any obstructions. The yard has a covered outdoor area. The entire back and sides of the property are fenced with 2 self-closing self latching gates and not bodies of water on the premises, Garbage cans are stored on the side of house and in an enclosed dumpster area.

LPA completed the inspection tool and did not have any concerns with licensing at this facility.

Exit interview conducted, a hard copy of report was provided via email for signature and return by mail to LPA.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2021

LIC809 (FAS) - (06/04)

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