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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071440693
Report Date: 11/16/2021
Date Signed: 11/16/2021 04:46:09 PM

Document Has Been Signed on 11/16/2021 04:46 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:PARK PLAZA REST HOMEFACILITY NUMBER:
071440693
ADMINISTRATOR:JOSEPH, JANICEFACILITY TYPE:
740
ADDRESS:4901 PLAZA WAYTELEPHONE:
(510) 233-3240
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY: 6CENSUS: 4DATE:
11/16/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Janice Joseph, AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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On 11/16/2021 at 2:35 PM, Licensing Program Analyst (LPA) Catherine Lin conducted case management while conducting Infection Control Inspection. LPA met with Administrator Janice Joseph and explained the purpose of the visit.

THE FOLLOWING DEFICIENCY WAS OBSERVED:
ยท At 3:00PM, LPA observed knives, cleaning and laundry supplies were accessible to residents.


The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2021
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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Document Has Been Signed on 11/16/2021 04:46 PM - It Cannot Be Edited


Created By: Catherine Lin On 11/16/2021 at 04:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PARK PLAZA REST HOME
FACILITY NUMBER: 071440693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2021
Section Cited
CCR
87705(f)(1)

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87705 Care of Persons with Dementia
(f)The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
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Administrator agreed to fix the lock to the garage, replace the lock of knife's cabinet, and submit photos to CCL by POC date.
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Based on observation, the licensee did not comply with the section cited above. LPA observed knives, cleaning and laundry supplies were accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
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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:Bennett Fong
LICENSING EVALUATOR NAME:Catherine Lin
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2021


LIC809 (FAS) - (06/04)
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