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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850052
Report Date: 08/24/2021
Date Signed: 08/24/2021 02:57:34 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 LIVINGFACILITY NUMBER:
405850052
ADMINISTRATOR:BARNHILL, DIANAFACILITY TYPE:
740
ADDRESS:7500 PORTOLA RDTELEPHONE:
(805) 591-9855
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:12CENSUS: 13DATE:
08/24/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:28 AM
MET WITH:Leticia Ruiz, Office Manager and Emma Maxwell, CaregiverTIME COMPLETED:
01:27 PM
NARRATIVE
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On 8/24/21 at 11:28 am, Licensing Program Analyst (LPA) Chavez visited the facility to follow-up on a Plan of Correction issued on 8/20/21. LPA met with Leticia Ruiz, Office Manager, and explained the reason for the visit. Ms. Ruiz confirmed that the facility currently has 13 residents and there were concerns with transferring the 13th resident out of the facility due to health issues. LPA reminded office manager that it was not required that the 13th resident is transferred, but rather one resident is moved out to be in compliance with the facility's licensed 12 residents. LPA left the facility at 11:37 am and returned again at 1:17 pm. LPA met with Emma Maxwell, Caregiver, and explained the reason for the visit. Emma phoned the administrator Diana Barnhill who stated she was not available to visit the facility and asked Emma to handle the visit and sign the report(s).

The facility has 13 residents, and therefore, is still not in compliance and being cited for deficiency. Civil penalties are being issued.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2021
Section Cited

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A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons…This requirement was not met as evidenced by:
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Census at facility. The licensee did not comply with capacity limitations facility has a current census of 13 and a license for 12 which poses an immediate health and safety risk to residents in care. A citation is being given after licensee did not complete POC to meet regulation on 8/21/21.
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License has agreed to move one resident out of the facility within 24 hours with approval from resident's family or person of responsbility to meet capacity of current license.

Civil Penalties Assessed.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2021
LIC809 (FAS) - (06/04)
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