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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601283
Report Date: 03/27/2023
Date Signed: 03/27/2023 02:58:49 PM


Document Has Been Signed on 03/27/2023 02:58 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:PARKVIEW, THEFACILITY NUMBER:
015601283
ADMINISTRATOR:ZAININGER, SYLVIAFACILITY TYPE:
740
ADDRESS:100 VALLEY AVETELEPHONE:
(925) 461-3042
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY:123CENSUS: 95DATE:
03/27/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Aireen Tibon, Executive DirectorTIME COMPLETED:
03:10 PM
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On 3/27/2023 at 1:30PM, Licensing Program Analysts (LPAs) G. Luk and K. Nguyen arrived unannounced to conduct a Case Management visit in regards to death report received on 3/22/2023. LPAs met with Executive Director, Aireen Tibon.

LPAs received death report on 3/22/2023 for resident (R1). Death report stated that resident was found on the floor unresponsive and staff called 911. Police arrived on scene.

LPAs interviewed two staff who stated PM shift provided medications to R1 at around 8-8:30PM and R1 was doing well with a good appetite. Record review indicated that R1 was diagnose with hypertension. When S1 arrived at R1's room for morning meds at around 5:40AM, S1 found R1 unresponsive on the floor. S1 called for assistance and called 911.

No deficiencies were cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023
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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