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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850052
Report Date: 10/31/2025
Date Signed: 11/05/2025 04:16:21 PM

Document Has Been Signed on 11/05/2025 04:16 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 PLACE ASSISTED LIVINGFACILITY NUMBER:
405850052
ADMINISTRATOR/
DIRECTOR:		BARNHILL, DIANAFACILITY TYPE:
740
ADDRESS:7500 PORTOLA RDTELEPHONE:
(805) 591-9855
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 13CENSUS: 10DATE:
10/31/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Diana Barnhill, AdministratorTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) De Leon conducted a case management -Incident visit to the facility above. LPA met with Diana Barnhill Licensee/Administrator of the facility and explained the purpose of the visit.

LPA toured the facility and checked on the 10 residents in care.
LPA requested the following records from the facility: Residents roster, Staff Roster, Staff Schedule for date of incident, copy of the video surveillance for 10/26/2025, 10 Residents care plans, Call pendants records for October 25th, 26th and 27th, and Copy of Staff 1 (S1)’s file for application, job description, mandated reporting, photo ID, CCL Clearance form, and training, as well as any remaining records not received from 10/27/2025 request.

Licensee called LPA on Monday October 27, 2025, at 12:30pm to report an incident that happened on Sunday Oct. 26, 2025, around 1:30am-5:30am, Staff 1 (S1) on duty NOC caregiver text Licensee and Staff 2 (S2) that S1 was not feeling good and was leaving to go home. This text message was not read until after 5:15 am by S2, who immediately called the facility and got no answer called the Licensee, changed and headed over to the residence. The front door was found unlocked and all 10 Residents were found sleeping around 5:35am, Licensee arrived at 6:03pm and Staff 3 (S3) arrived before the start of S3’s 6am shift at 5:51am. The Licensee said company policy is for Staff to call and not to text when in an emergency. Continued 809-C
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PARK PLACE ASSISTED LIVING
FACILITY NUMBER: 405850052
VISIT DATE: 10/31/2025
NARRATIVE
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LPA requested records from Licensee on 10/27/2025 after learning of the incident: Video Surveillance for 10/26/2025, Incident Report, SOC 341 sent to local law enforcement, Long Term Care Ombudsman (LTCO) and CCL. S1’s full name, address and phone number, call pendant calls for 10/26/2025 for all residents in care, list of residents that get up during the night and a list of residents that need toileting or briefs changes during the night, if S1 worked in the Licensee’s other facility, in which S1 did, Job description for Caregiver on NOC shift and a copy of S1’s texts to Licensee and S2.

The Licensee sent the Incident Report on Monday October 27, 2025, at 1:34pm to Community Care Licensing (CCL) which provided additional details. S1 text message Licensee and S2 at 1:21am and after reviewing the video surveillance S1 left the facility at 1:23am. The residents were alone in the facility from 1:23am to around 5:39am when S2 arrived. Staff checked on residents, a few of them needed to be changed and had been left soiled and wet. The Licensee tried to call and Text S1 with no response and S1 was terminated on 10/27/2025 for the neglect of 10 residents in care by leaving them alone in the facility.

S2 verified the text came into S2's phone at 1:23am and S2 did not hear the text message then upon waking read the message and immediately called the facility with no answer, then proceeded to get dressed and drove straight over to the facility and arrived at 5:39am, door was unlocked, checked residents in care and all 10 were accounted for and sleeping. S2 watched the video surveillance which showed Resident 1 (R1) had gotten up out of bed and set off the floor alarm and proceeded to the dining room around 1:23am, S1 had just walked out the door at this time video shows S1 turned around and came back into the facility and redirected R1 to R1's room, S1 proceeded to leave out the door again, front door unlocked and left the facility with 10 residents in care alone until 5:39am. S2 watched the full video and said no other residents got up from 1:30am- 5:39am when S2 arrived at the facility.

Licensee watched the videos and confirmed the times of the incident.

Continued 809-C
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PARK PLACE ASSISTED LIVING
FACILITY NUMBER: 405850052
VISIT DATE: 10/31/2025
NARRATIVE
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LPA attempted to call S1 on 10/31/2025 at 8:49am the phone had restrictions set and would not accept LPA's call, LPA text on 10/31/2025 at 8:58am with a picture of business card and asking S1 to call LPA due to having restrictions set on phone was not able to call or leave a message. LPA attempted to call again on 10/31/2025 at 9:05am the phone number on file and was not able to get through due to restrictions being set on the phone number. LPA attempted 1 more call to S1's phone at 10:02am and the call would not go thorough.

Exit interview conducted, deficiency cited, civil penalty assessed, copy of report and appeal rights printed for Administrator.
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/31/2025 10:38 AM - It Cannot Be Edited


Created By: Rachael De Leon On 10/31/2025 at 10:04 AM
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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PARK PLACE ASSISTED LIVING
FACILITY NUMBER: 405850052

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2025
Section Cited
CCR
87411(a)

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(a)Facility personnel shall at all times be sufficient in numbers, ...competent to provide the services necessary to meet resident needs. ...This requirement was not met as evidenced by:
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The Licensee agreed to schedule adequate staff coverage and send schedules to CCL for the next 90days. Train facility personnel in Facility Policy and Procedures for calling out, leaving the facility, and Cont. below
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Based on interviews, video surveillance, incident reports, the Licensee failed to comply with the regulation above S1 left shift at 1:23am leaving 10 residents alone for over 4 hours which possess an immediate health, safety and personal rights risk to residents in care.
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contact names and numbers to call when an emergency need arises, send proof of training and LIC 500 with all current staff listed.

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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.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Rachael De Leon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2025


LIC809 (FAS) - (06/04)
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