<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300613274
Report Date: 02/22/2022
Date Signed: 02/22/2022 04:09:47 PM

Document Has Been Signed on 02/22/2022 04:09 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:PARK VISTA AT MORNINGSIDEFACILITY NUMBER:
300613274
ADMINISTRATOR:HAIDY MIKHAEL ANDRAWESFACILITY TYPE:
740
ADDRESS:2527 BREA BLVDTELEPHONE:
(714) 256-8008
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY: 85CENSUS: 59DATE:
02/22/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Richard Nordsiek and Jessica Todd TIME COMPLETED:
04:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Kathrina Chin made an unannounced site visit as a follow up to a case management- incident. LPA Chin identified herself and LPA spoke Richard Nordsiek, Executive Director and Jessica Todd, Assisted Living Director regarding a self reported incident which occurred on February 11, 2022.

On 2/11/2022, resident 1 who resides in the Memory Care Unit, needed urinary testing due to possible UTI. The results came back the same day and indicated an unusual finding. A second urinary test was conducted with contradictory results. Forensic testing was conducted and the results are still pending. Staff 1 was immediately suspended and is currently not working at the facility. The facility submitted both an unusual incident report and SOC 341 Report of Suspected Dependent Adult/Elder Abuse to the licensing office.

LPA interviewed resident 1.

No deficiency cited this review as per Title 22 of the California Code of Regulations.

An exit interview was conducted with Administrator and a copy of this report was provided to Administrator.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kathrina Chin
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1