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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608336
Report Date: 09/12/2022
Date Signed: 09/12/2022 04:30:44 PM

Document Has Been Signed on 09/12/2022 04:30 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GREENPARK MANORFACILITY NUMBER:
197608336
ADMINISTRATOR:GLADYS PERVEZFACILITY TYPE:
740
ADDRESS:903 N. GREENPARK AVENUETELEPHONE:
(626) 859-7513
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY: 6CENSUS: 6DATE:
09/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Gladys Pervez, administratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Gladys Pervez who assisted with visit. The facility is licensed to serve one (1) bedridden and five (5) non-ambulatory residents (ages 60 and above). The facility has an approved Hospice Waiver for five (5) residents. Currently, there are six (6) residents in placement including three (3) hospice residents. Annual licensing fees are current. Administrator certificate is current and the expiration date is 02/08/23.

During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed.



The facility is located in a residential neighborhood. LPA toured the facilities physical plant, indoor and outdoor. LPA observed the facility to have four (4) resident bedrooms, two (2) bathrooms, living room, dining room, kitchen, garage equipped with a laundry area and an indoor/outdoor activity area. All the rooms were furnished with appropriate furniture for residents’ comfort. The bathrooms were furnished with grab bars and nonskid surfaces. Common areas were observed for the ability to safely serve the needs of the residents. Hot water temperature was 119.0 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies was observed. No pools and bodies of water on the premises. Facility maintained a comfortable temperature for residents. Auditory alarm devices to monitor exits were operable. Interior and exterior space available to permit residents to wander freely and safely. Last fire drill was conducted on 8/30/22.

Sufficient supply of perishable and nonperishable foods is observed. Knives, tools, sharp items are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable. Fire extinguishers’ last service is 3/10/22 and are fully charged.
(-continued in LIC 809C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2022
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GREENPARK MANOR
FACILITY NUMBER: 197608336
VISIT DATE: 09/12/2022
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The first aid kit is fully stocked. Mandated documents and signages are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication is centrally stored in a locked cabinet in med room and inaccessible to residents. Resident records are stored and locked in med room, inaccessible to residents. Toxic substances are inaccessible to residents. Outdoor facility space used for residents and leisure are completely enclosed by a fence with self-closing gates.

No deficiencies were observed and cited per California Code of Regulations, Title 22.

An exit interview was conducted. This report was discussed with Administrator, Gladys Pervez's signature on this form confirmed receipt of these documents. A copy of LIC 809s report was provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022
LIC809 (FAS) - (06/04)
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