300613274-1-17-2023-22-AS-LADS-CN9V8E-20230120151239

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 300613274
Report Date: 12/15/2022
Date Signed: 01/17/2023 09:14:03 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/27/2022 and conducted by Evaluator Jenifer Tirre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221027143753

FACILITY NAME:	PARK VISTA AT MORNINGSIDE		FACILITY NUMBER:	300613274
ADMINISTRATOR:	HAIDY MIKHAEL ANDRAWES		FACILITY TYPE:	740
ADDRESS:	2527 BREA BLVD		TELEPHONE:	(714) 256-8008
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92835
CAPACITY:	85	CENSUS: 61	DATE:	12/15/2022
		UNANNOUNCED	TIME BEGAN:	12:36 PM
MET WITH:	Assisted Living Director, Jessica Todd		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Facility does not follow resident's proper diet

INVESTIGATION FINDINGS:

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On this day Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit to follow up on complaint investigation. LPA discussed purpose of the visit and allegations with Assisted Living Director Jessica Todd.

The department investigated this complaint and investigation consisted of interviews and documentation. Investigation revealed that Resident (R1) was a resident in facility's Skilled Nursing Facility not Assisted Living.
Resident was present in Park Vista's Skilled Nursing from 10/18/22 to 10/29/22.
Park Vista's Skilled Nursing is an entity of California Department of Public Health. This agency has investigated the complaint alleging facility does not follow resident's proper diet. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without reasonable basis.

An exit interview was conducted with Assistant Living Director and a copy of report was provided to facility.
***THIS IS AN AMENDED REPORT***

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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