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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603545
Report Date: 10/29/2024
Date Signed: 10/29/2024 01:43:06 PM

Document Has Been Signed on 10/29/2024 01:43 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PARK VIEW PLACEFACILITY NUMBER:
198603545
ADMINISTRATOR/
DIRECTOR:		LEEANN HEFNERFACILITY TYPE:
740
ADDRESS:1054 PARK VIEW DRIVETELEPHONE:
(626) 885-1800
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY: 142CENSUS: 84DATE:
10/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:LeeAnn Hefner, administratorTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced Case Management- Incident visit in response to resident#1 (R1) Incident Report, dated 10/05/24. The facility has a capacity of 142 residents, licensed to serve elderly residents age 60 and above, approved for 142 non-ambulatory residents and has dementia program in place. LPA explained the purpose of today's visit to LeeAnn Hefner, administrator who assisted with this visit.

During today's visit, LPA conducted physical plant, conducted interviews including Administrator, staff#2-staff#3, resident#1 (R1) and family member (FM), reviewed R1's file and staff file. LPA attempted but unable to reach staff#4 (S4) and the agency caregiver (S5) for interview. The incident report stated an agency caregiver (S5) reported to administrator that staff#4 (S4) was rough with resident#1 (R1) while providing care. The agency caregiver reported S4 did not use the Hoyer Lift to transfer resident, grabbed resident by resident’ neck and did not provide proper pericare to resident. LPA interviewed Administrator/staff revealed that the facility investigated the incident, put the alleged staff (S4) on an immediate suspension on 10/04/24, and reported the incident to Licensing/ ombudsman / responsible party/ police on 10/05/24. The staff interviews revealed it was a single incident and resident#1 (R1) was not injured nor physically abused. Staff S4 was a new hired and had completed training on providing care to dementia residents. S4 was voluntarily terminated on 10/07/24 after the incident. After the incident, the administrator hosted a brief meeting with caregivers regarding the proper procedures on providing cares to residents with dementia and using Hoyer Lift. Per interview of R1, resident seemed unable to recall the incident and did not observe injury on resident’s neck or back. R1 was on a daily monitor by staff for a week. FM interview revealed R1 was doing fine and did not complain any pain after the incident. Police case#24-22261.
(-continued on LIC 809C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/29/2024
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LPA obtained copies of the following documents:

· Staff roster
· Resident roster
· R1’s Identification/Emergency Contact Information (facesheet)
· Unusual Incident Report
· Physician Report
· Staff #4 staff files/document
· In-service training

LPA did not observe nor identify signs of neglect, abuse or other immediate health and safety threats. No deficiencies were observed and cited during this visit. Exit interview was held with administrator and this report LIC 809 was provided to administrator.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC809 (FAS) - (06/04)
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