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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530231
Report Date: 06/18/2024
Date Signed: 07/22/2024 04:30:36 PM

Document Has Been Signed on 07/22/2024 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
CENTRALIZED APP UNIT, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:PARKMOUNT MANORFACILITY NUMBER:
335530231
ADMINISTRATOR/
DIRECTOR:		PINTO, LEAHFACILITY TYPE:
740
ADDRESS:1001 YARDLEY WAYTELEPHONE:
(951) 870-7189
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY: 6CENSUS: 0DATE:
06/18/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Geoffrey Brouillette; Leah PintoTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Facility Type: Initial
Application Type: RCFE
Capacity: 6
Census (if any clients in care): 0
COMP II Participants: Geoffrey Brouillette; Leah Pinto - Applicant/Adminsitrator
Interview Method: Virtual interview

On 06/18/2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Ahmad Reshad
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
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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