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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300613274
Report Date: 09/02/2022
Date Signed: 09/02/2022 05:19:04 PM


Document Has Been Signed on 09/02/2022 05:19 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: 54DATE:
09/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:27 PM
MET WITH:Chris Oakeson , Executive DirectorTIME COMPLETED:
05:25 PM
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Licensing Program Analyst (LPA), Kathrina Chin made an unannounced site visit as a follow up to a case management- incident., LPA, Kathrina Chin met with Chris Oakeson, Executive Director and Jessica Todd, Assisted Living Director regarding a self reported incident which occurred on February 11, 2022.

LPA, Kathrina Chin returned to the facility and was informed that the forensic test results was negative.

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. Staff 1 was immediately suspended and no longer 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 did not observe a deficiency during today's visit.


An exit interview was conducted and a copy of this report was provided to Administrator.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2022
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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