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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802269
Report Date: 10/13/2022
Date Signed: 10/13/2022 04:46:36 PM

Document Has Been Signed on 10/13/2022 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:PARK GROVE, THEFACILITY NUMBER:
405802269
ADMINISTRATOR:MARCOS, SISENANDO M JRFACILITY TYPE:
740
ADDRESS:338 MARGARITA AVETELEPHONE:
(805) 541-1772
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY: 6CENSUS: 4DATE:
10/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:13 PM
MET WITH:Sisenando Marcos, Jr., Licensee, and Susan Claire Marcos, AdministratorTIME COMPLETED:
04:55 PM
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On 10/13/22 at 3:13 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Susan Claire Marcos, Administrator, and Sisenando Marcos, Jr., Licensee, and explained the purpose of the visit.

LPA toured the facility with the licensee and administrator and observed the following: The facility has infection control signage at the front door. The facility has signage throughout the facility on handwashing, cough etiquette and use of masks. Upon entry to the facility, LPA was screened and asked to sign-in. Staff are wearing masks. The facility has soap and paper towels in resident bathrooms (2). Fire extinguishers are located in the kitchen and hall near resident bedrooms. The extinguishers are fully charged and were inspected on 1/21/22. The facility has an 8.5”x11” CDSS Complaint Poster. Licensee will have a 20”x26” regulation poster displayed in a common area, take a photo, and send to LPA by 10/20/22.

At 3:45 pm, LPA conducted the Infection Control mitigation module with the licensee and administrator. No deficiencies cited.

Exit interview conducted and report emailed to the licensee.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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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