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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001157
Report Date: 06/21/2021
Date Signed: 06/21/2021 12:01:15 PM

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 TERRACEFACILITY NUMBER:
306001157
ADMINISTRATOR:KOEHLER, EUGENE (GENO)FACILITY TYPE:
740
ADDRESS:21952 BUENA SUERTETELEPHONE:
(949) 888-2250
CITY:RANCHO SANTA MARGARISTATE: CAZIP CODE:
92688
CAPACITY:230CENSUS: 167DATE:
06/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ito ChongTIME COMPLETED:
12:15 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) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required inspection visit. LPA was greeted by receptionist and proceeded with check in process. LPA advised receptionist reason for the visit. LPA met with Ito Chong and explained the nature of today’s visit.

LPA began the tour of the facility along with facility representative. Facility has 167 residents in care during today’s visit. LPA observed residents in common spaces and outdoor patio relaxing. All residents appeared happy and well taken care of. Facility appears clean and sanitary in all areas observed. All residents’ rooms had the required elements as well as restrooms stocked with soap/sanitizer. Restrooms have hand washing signage posted. Facility screens all staff and visitor to the facility electronically. Upon entry LPA was screened with covid questioner and temperature check done electronically. Facility documents daily check in results electronically. Facility has covid precaution posting as well as all required Department postings. Facility has completed the submittal process of the mitigation plan and LPA reviewed the emergency disaster plan folder. LPA observed adequate emergency food and water supply. First aid kits are kept in all medication carts, front desk, kitchen and medication room. LPA tested the hot water temperature in bathrooms which are used by residents. The hot water temperature measured 115.4-117.9 Fahrenheit degrees through the first floor, second floor and memory care unit. Facility has an ample supply of PPE, incontinence, and cleaning supplies. Facility has sanitizer precaution in place mounted on the wall though out the facility in all common spaces. LPA toured the outside and observed ample shaded outside space for residents and outdoor visitation. LPA observed medication room with automatic medication supply delivery every 30 days. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation as needed. Facility bedrooms are an apartment style unit. All staff and residents have been vaccinated for Covid-19.

Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.
This report was reviewed with Facility Representative and a copy of this report was provided and left at facility.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021
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