300613274-11-25-2024-22-AS-EKIM-DBD362-20241125165736

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300613274
Report Date: 11/25/2024
Date Signed: 11/25/2024 04:57:46 PM

Document Has Been Signed on 11/25/2024 04:57 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	PARK VISTA AT MORNINGSIDE		FACILITY NUMBER:	300613274
ADMINISTRATOR/ DIRECTOR:	HAIDY MIKHAEL ANDRAWES		FACILITY TYPE:	740
ADDRESS:	2527 BREA BLVD		TELEPHONE:	(714) 256-8008
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92835
CAPACITY: 85	TOTAL ENROLLED CHILDREN: 0	CENSUS: 62	DATE:	11/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Executive Director- Christopher Oakeson		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

NARRATIVE

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On November 25, 2024, at 8:00am, Licensing Program Analysts (LPAs) Edward Kim and Eboni Bentley conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPAs Kim and Bentley were greeted and granted entry by staff. LPAs Kim and Bentley met with Executive Director (ED) Christopher Oakeson and explained the purpose of the visit.

The facility is licensed to operate for eighty-five (85) nonambulatory residents of which ten (10) may be bedridden and have a hospice waiver for ten (10) residents. The facility consists of an Assisted Living two-story structure and a one story memory care structure, which consists of the following: sixty-eight (68) resident bedrooms, five (5) offices, seventy-three (73) bathrooms, living area, two dining areas, two (2) TV rooms, two kitchens, two dining areas, lounge, assisted living outdoor patio area, and a memory care outdoor patio area.

LPAs Kim and Bentley toured inside and outside of the physical plant with ED Oakeson. There were no obstructions on the premises. A small fountain was in the assisted living courtyard. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Assisted Living (AL) Resident Room 111, AL Resident Room 114, AL Resident Room 120, AL Resident Room 124, AL Resident Room 201, AL Resident Room 203, AL Resident Room 204, AL Resident Room 208, AL Resident Room 217, Memory Care (MC) Resident Room 105, and MC Resident Room 110. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 105.4 degrees F to 116.8 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility. The facility has eighteen (18) fire extinguishers that were charged, mounted throughout the facility, and serviced on February 15, 2024.

Evaluation Report Continues on LIC 809-C

Lourdes Montoya	TELEPHONE: (916) 956-7332
Edward Kim	TELEPHONE: (714) 293-1237
	DATE: 11/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PARK VISTA AT MORNINGSIDE	FACILITY NUMBER: 300613274
	VISIT DATE: 11/25/2024

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LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food, emergency water, and emergency supplies were stored in the storage room.

During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The smoke detectors and carbon monoxide detectors were inspected by National Fail-Safe annually and last serviced on May 09-10, 2024. Johnson Controls conducts a quarterly test on the sprinkler system and last serviced on November 8, 2024. A working telephone (714-256-8111) and an internet capable device for teleconferencing purposes remains available.

LPA Kim conducted an audit of eight (8) resident files (R1-R8), nine (9) staff files (S1-S9), and medication and medication administration record were all in order and complete. LPA Kim conducted six (6) staff interviews and four (4) resident interviews.

A deficiency was cited during this inspection visit according to the California Code of Regulations (Title 22, Division 6, Chapter 8)

An exit interview was conducted, and a copy of this report and the appeal rights were provided to Executive Director Christopher Oakeson

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 11/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/25/2024 04:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PARK VISTA AT MORNINGSIDE	FACILITY NUMBER: 300613274
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review, and interview the licensee did not comply with the section cited above. LPA observed R1 is diagnosed with dementia but in the room there was a clorox spray bottle around the sink. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/06/2024
	Plan of Correction
1 2 3 4	Licensee states they will remove the clorox spray bottle, any other cleaning supplies, and any other potential tools such as scissors from R1's room. Licensee will send proof of completed POC through email to CCLD via email to edward.kim@dss.ca.gov by POC due date December 6, 2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Lourdes Montoya	TELEPHONE: (916) 956-7332
Edward Kim	TELEPHONE: (714) 293-1237
	DATE: 11/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024

LIC809 (FAS) - (06/04)

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