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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603545
Report Date: 02/13/2025
Date Signed: 02/13/2025 04:21:34 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/28/2024 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241028085133
FACILITY NAME:PARK VIEW PLACEFACILITY NUMBER:
198603545
ADMINISTRATOR:LEEANN HEFNERFACILITY TYPE:
740
ADDRESS:1054 PARK VIEW DRIVETELEPHONE:
(626) 885-1800
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY:142CENSUS: 84DATE:
02/13/2025
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Administrator Leann HefnerTIME COMPLETED:
04:25 PM
ALLEGATION(S):
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Staff did not dispense residents’ medication as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent unannounced complaint investigation visit for the allegation(s) listed above. LPA met with staff Melodie Misaikone and the purpose of the visit was discussed. Administrator Leann Hefner was notified via phonecall. Adminstrator arrived shortly after.

As of todays visit: LPA has toured the physical plant, interviewed Staff #1-7 (S1-S7), interviewed residents #1-#6 (R1-R6), interviewed R1's home health agency (W1),collected copies of the staff and resident rosters, collected copies of documents from R1's file related to the allegations.

The investigation revealed the following:
In regards to the allegation "Staff did not dispense residents’ medication as prescribed." it is alleged that R1 went two days without receiving the proper medications. (3) of (7) Staff confirmed the allegation. (6) of (6) Residents interviewed could not corroborate the allegation...
Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/28/2024 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241028085133

FACILITY NAME:PARK VIEW PLACEFACILITY NUMBER:
198603545
ADMINISTRATOR:LEEANN HEFNERFACILITY TYPE:
740
ADDRESS:1054 PARK VIEW DRIVETELEPHONE:
(626) 885-1800
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY:142CENSUS: 84DATE:
02/13/2025
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Administrator Leann HefnerTIME COMPLETED:
04:25 PM
ALLEGATION(S):
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Staff did not provide adequate supervision, resulting in a resident sustaining multiple falls.
Staff neglect resulted in resident sustaining an unexplained injury.
Staff did not assist resident with eating.
Staff did not communicate with resident's authorized representative regarding care in a timely manner.
Staff did not provide resident’s records to authorized representative in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent unannounced complaint investigation visit for the allegation(s) listed above. LPA met with staff Melodie Misaikone and the purpose of the visit was discussed. Administrator Leann Hefner was notified via phonecall. Adminstrator arrived shortly after.

As of todays visit: LPA has toured the physical plant, interviewed Staff #1-7 (S1-S7), interviewed residents #1-#6 (R1-R6), interviewed R1's home health agency (W1),collected copies of the staff and resident rosters, collected copies of documents from R1's file related to the allegations.

The investigation revealed the following:


CONTINUED ON LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20241028085133
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PARK VIEW PLACE
FACILITY NUMBER: 198603545
VISIT DATE: 02/13/2025
NARRATIVE
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In regards to the allegation "Staff did not provide adequate supervision, resulting in a resident sustaining multiple falls" it is alleged that R1 has had multiple falls in the facility in the last year due to lack of supervision. (7) of (7) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interviews with staff only showed knowledge of one fall where R1 slipped from their wheelchair. Staff were present and able to assess R1. 911 was also called but no injuries were noted. File review shows an SIR dated 6/2/24 on the incident provided to licensing. There were no other recordings of falls R1 may have had in the facility. Based on observations, file reviews, and interviews conducted there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

In regards to the allegation "Staff neglect resulted in resident sustaining an unexplained injury" it is alleged that due to staff neglect of supervision R1 received a unknown burn on their hand. (7) of (7) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interviews stated that blisters were observed on R1's hand on 10/8/24. Staff interviewed denied any knowledge of what caused the blisters. Interviews added that the blisters were initially observed by R1's relative while they were in private. Once staff became aware, they assessed R1 and called paramedics. There was no knowledge of the blister prior to the family visit. File review shows there is an incident report on file for this day. Staff stated there are no chemicals in the open near R1's bed and R1 receives total assistance with mobility around the facility. This means staff are present and near R1 when moving anywhere in the facility. Interview with R1's home health agency stated the blisters classify as a burn but the cause remains unknown. The blister was in between the finger and more resembled friction burn rather than a chemical burn. LPA observed R1's room to be free of any items that pose a danger. LPA observed staff supervision to be sufficient. Based on observations, file reviews, and interviews conducted there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Continued on LIC 9099-C
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20241028085133
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PARK VIEW PLACE
FACILITY NUMBER: 198603545
VISIT DATE: 02/13/2025
NARRATIVE
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In regards to the allegation "Staff did not assist resident with eating" it is alleged that staff did not assist R1 with eating their meals after their left hand was bandaged. (7) of (7) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interviews stated that R1 had a bandaged left hand but eats with their right hand. Staff interviewed stated that R1's care plan requires cut up food and encouragement but not to be fed directly. Staff stated they however do make sure R1 finishes their meals and will assist if R1 needs it. LPA observed R1 eating in the facility on their own during the initial visit. Based on observations, file reviews, and interviews conducted there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

In regards to the allegation "Staff did not provide resident’s records to authorized representative in a timely manner" it is alleged that R1's family requested resident records but the facility would not provide them. (7) of (7) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interview with staff stated that R1's responsible party requested, in writing, for a list of documents from R1's file on 10/29/24. Staff stated the documents have been gathered as of 10/31/24 and R1's responsible party was notified they can be picked up. File review confirms the date of the request and the date the documents were provided. Based on observations, file reviews, and interviews conducted there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

In regards to the allegation "Staff did not communicate with resident's authorized representative regarding care in a timely manner" it is alleged that the facility has not communicated any changes in R1's care plan since R1 moved in. (7) of (7) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Staff interviewed stated R1 moved in on 11/24/23 and there have been no changes since the finalized care plan completed on 1/26/24. This plan was communicated with R1's responsible party. File review showed last service plan on file for R1 was created on 1/26/24. Staff stated the plan is still current and there have been no changes. LPA was not informed of what changed were done that needed to be communicated. Based on observations, file reviews, and interviews conducted there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 28-AS-20241028085133
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PARK VIEW PLACE
FACILITY NUMBER: 198603545
VISIT DATE: 02/13/2025
NARRATIVE
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Interviews showed that there were medication errors on 9/1/24 and 9/2/24 for R1 regarding their Depakote medication. On 9/4/24, Staff observed the medication still in the bubble pack for those two days meaning that R1 did not receive it. Review of R1's file shows that R1 requires assistance with medication from staff. File review also showed an incident report was created to report the missing medications to licensing and in service training was scheduled with staff. This shows that the facility failed to dispense R1's medication as prescribed. Based on LPA's observations, record reviews and interviews conducted the preponderance of evidence standard has continue therefore the above allegations are found SUBSTANTIATED.

Deficiency is being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8 on LIC 9099D.

Exit interview conducted. Appeal rights discussed. A copy of this report and the appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20241028085133
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PARK VIEW PLACE
FACILITY NUMBER: 198603545
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2025
Section Cited
CCR
87465(a)(4)
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87465(a) A plan for incidental medical and dental care shall be developed...The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed.
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POC cleared at the time of the visit.

Facility has reported incident as required and conducted in-service training for staff that assist residents with medication.
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This requirement was not met as evidenced by:
R1 was not assisted with their Depakote medication between 9/1-9/2/24 which poses an immediate health and safety risk to residents in care.
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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.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6