<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850052
Report Date: 03/03/2022
Date Signed: 03/03/2022 03:19:29 PM


Document Has Been Signed on 03/03/2022 03:19 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:PARK PLACE ASSISTED LIVINGFACILITY NUMBER:
405850052
ADMINISTRATOR:BARNHILL, DIANAFACILITY TYPE:
740
ADDRESS:7500 PORTOLA RDTELEPHONE:
(805) 591-9855
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:13CENSUS: 13DATE:
03/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:Leticia Ruiz, Office ManagerTIME COMPLETED:
12:15 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
On 3/03/22 at 11:01 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Office Manager Leticia Ruiz and explained the purpose of the visit.

LPA toured the facility with office manager and observed the following: The facility has signage at the front door regarding the visitor policy. LPA was screened upon entry. The facility has seven single-occupancy resident rooms and three double-occupancy resident rooms. Each room includes an attached bathroom. Individual resident bathrooms and the bathrooms in the common areas were stocked with soap and paper towels. The facility has signage for COVID infection control measures including cough etiquette and handwashing reminders. There are two fire extinguishers, one located in the hall next to the laundry and the other in the hall near the resident tv area. Both are fully charged and were inspected on 8/26/2021. LPA observed all staff wearing surgical masks properly. The facility has a 11”x14” Community Care Licensing Complaint poster in a common area, however, regulation requires a 20”x26” poster. Licensee will ensure the proper size poster is displayed.

At 11:20 am, LPA conducted the Infection Control mitigation module with the office manager. No deficiencies cited.

Exit interview conducted and report emailed to the licensee.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1