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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071440693
Report Date: 05/12/2023
Date Signed: 05/16/2023 10:14:39 AM


Document Has Been Signed on 05/16/2023 10:14 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/12/2023 02:48 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

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Amended report on 05/16/23 to reflect the day, time, LPA and continuation page from 05/12/23 at 08:10 AM; Licensing Program Analyst (LPA) L. Holmes conducted an unannounced required annual inspection. LPA met with Janice Joseph, Administrator (ADM), and explained the purpose of the visit. LPA toured the facility with ADM who currently holds a certificate (#6025466740) that expired on 03/15/23; renewal paid and not yet received. The facility’s fire clearance was approved for six (6) non-ambulatory residents; all six (6) may be non-ambulatory and one (1) may be hospice.

Upon arrival LPA observed two (2) staff attending to residents and the two (2) residents were dining. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of five (5) total bedrooms which two (2) are occupied by the residents. All outdoor and indoor passageways are free of obstruction. The body of water is enclosed. A comfortable temperature was maintained at 75 degrees Fahrenheit (F). LPA observed lighting in all rooms to be adequate for the comfort and safety of the residents. Hot water temperature in the shared residents bathroom was measured at 116.5 degrees (F). All toilets, hand washing, and bathing areas were safe, sanitary and in operating condition. Hand washing poster, paper towels, and soap observed at all hand washing stations. Linen and hygiene products were available for residents. PPE, sanitizer, and paper goods are sufficient.

...continued on LIC809C.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: PARK PLAZA REST HOME
FACILITY NUMBER: 071440693
VISIT DATE: 05/12/2023
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...continued from LIC809

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was purchased on 05/20/22 and is full. Emergency Disaster Plan is updated. First aid kit was complete and emergency kits for each resident. Fire drills are conducted quarterly.

Five (5) of five (5) Staff records were reviewed, and all staff have criminal record clearance. All three (3) residents records reviewed were current and complete.

The following forms are to be updated and submitted to CCLD 05/30/23:
-Resident roster
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC610E Emergency Disaster Plan (Reviewed)
-An updated copy of Administrator Certificate(s)
-Create emergency binder
-Update staffs files with first aid/CPR certification
-Update staffs annual training records

No deficiencies cited during visit.
Exit interview conducted and a copy of this report provided to ADM.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2