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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850052
Report Date: 08/20/2021
Date Signed: 08/20/2021 02:02:23 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2021 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20210819140101
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:
08/20/2021
UNANNOUNCEDTIME BEGAN:
10:46 AM
MET WITH:Lorraine Hurst, CaregiverTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility is operating beyond the terms and conditions of the license
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Chavez conducted a 10-day complaint investigation visit to the facility above. LPA met with caregiver Lorraine Hurst and explained the reason for the visit.

It was reported to Community Care Licensing (CCL) that the facility above was over capacity. LPA verified census with Licensee/Administrator to be 13. CCL received an application from the Licensee for an increase of capacity; however, the application has not been approved due to documentation pending from the Licensee. The facility license is authorized for a capacity of 12, therefore the facility is not in compliance with regulation requirements. LPA requested Licensee to complete the application documentation and submit to CCL as soon as possible. LPA also instructed Licensee to immediately move one resident to another facility with approval from resident’s family or person of responsibility. Based on the information obtained, the allegation "Facility is operating beyond the terms and conditions of the license" is Substantiated.

Exit interview conducted, deficiency cited, report and appeal rights emailed to Licensee.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 29-AS-20210819140101
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/21/2021
Section Cited
CCR
87204(a)
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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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Licensee agreed to finalize application for capacity increase and provide a written statement stating the Licensee will not accept any further residents in care until the outcome of the application is decided, regardless of the outcome of application. Licensee will move forward in compliance with capacity limitations.
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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.
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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 Penalty 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: 08/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
LIC9099 (FAS) - (06/04)
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