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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530231
Report Date: 09/18/2024
Date Signed: 09/18/2024 11:48:29 AM

Document Has Been Signed on 09/18/2024 11:48 AM - 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
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:
09/18/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:39 AM
MET WITH:Applicant/Administrator Geoffrey Brouillette and Administrator Leah PintoTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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On 09/18/2024 at 09:00 AM, Licensing Program Analysts (LPAs) Melody Brown, Raquel Hernandez and Eldin Serrano conducted an announced visit to the facility for purpose of Prelicensing evaluation. LPAs met with Applicant Geoffrey Brouillette, Administrator Leah Pinto. An initial application to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 02/10/2024 for a total capacity of six (6) of which five (5) can be nonambulatory and one (1) bedridden. Fire clearance was granted on 05/02/2024 for five (5) non-ambulatory residents and one (1) bedridden. LPAs Brown, Hernandez and Serrano observed the following:
Structure:
Facility was a one (1) story house with three (3) resident bedrooms, one (1) staff bedroom and two (2) bathrooms, living room, dining area/kitchen and laundry. There was an attached two (2) car garage in the left side of the house.
Heating/Cooling System:
Central heating and air conditioning system installed with one (1) central panel located in the hallway to
control entire house.
Bedrooms:
Each resident bedrooms accommodate any non ambulatory residents and bedroom #4 is for bedridden resident. All resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, night stands, a lamp and an operable smoke/carbon monoxide alarm.
Bathrooms:
The two (2) resident/staff bathrooms have a working toilet, wash basin, grab bars, non-slip mat and shower with an adequate supply of toilet paper and soap. LPAs Brown, Hernandez and Serrano tested the water temperatures in the residents' bathrooms. Tested at 113 degrees.

***CONTINUED ON LIC 809-C***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: PARKMOUNT MANOR
FACILITY NUMBER: 335530231
VISIT DATE: 09/18/2024
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***CONTINUED FROM LIC 809***
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives/sharp instruments
were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPAs Brown, Hernandez and Serrano observed the stove to be operational. Refrigerator/freezer were in working condition. There is sufficient storage for perishable food. There was adequate seating for meals for all residents. Laundry room with washer and dryer. Laundry detergents and cleaning supplies were observed in a locked cabinet. Garage door is locked away from residents.
Living Room:
There was a living/family room with adequate seating for all clients.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the hallway of the residence.
Yards/Outside:
Patio furniture for outdoor seating observed. Self-latching handle gate on left side of the house that leads
into the backyard. All outdoor pathways were free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Facility sketch was observed posted near the main entrance. There was Let-Us-No poster, Ombudsman Poster and Labor Laws observed.
Dementia Care Plan:
LPAs Brown, Hernandez and Serrano observed and reviewed the Dementia Care Plan during the visit.
General items:
One (1) fire extinguisher was charged and located in the kitchen. Five (5) combined smoke detectors and carbon monoxide detectors were tested and were observed to be in working order. Resident records and staff records will be stored in a locked cabinet in the living room. First Aid kit with required components, FirstAid Book and locked area for medication storage was observed. LPAs Brown, Hernandez and Serrano observed a facility phone and was operational as evidenced by LPAs dialing the number. The phone number designated for the facility is (951)-547-4546. There is enough Emergency water supply and the required 72-hour emergency food supply for residents and staffs available at the facility. Component III was completed on this day as well. Additionally, LPAs Brown, Hernandez and Serrano observed facility having Visitor Sign In/Sign Out Sheet and Resident Sign In/Sign Out Sheet, upon entering facility. **Continuation on LIC809C**
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: PARKMOUNT MANOR
FACILITY NUMBER: 335530231
VISIT DATE: 09/18/2024
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 The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22, Division 6, Chapters 1 and 6 to ensure the health and safety of residents in care. Facility appears to be ready for licensure.


An exit interview was conducted, and a copy of this report, LIC809 was discussed and provided to Applicant/Administrator Geoffrey Brouillette and Administrator Leah Pinto.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC809 (FAS) - (06/04)
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