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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001157
Report Date: 06/16/2025
Date Signed: 06/16/2025 12:47:41 PM

Document Has Been Signed on 06/16/2025 12:47 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 TERRACEFACILITY NUMBER:
306001157
ADMINISTRATOR/
DIRECTOR:		KOEHLER, EUGENE (GENO)FACILITY TYPE:
740
ADDRESS:21952 BUENA SUERTETELEPHONE:
(949) 888-2250
CITY:RANCHO SANTA MARGARISTATE: CAZIP CODE:
92688
CAPACITY: 230TOTAL ENROLLED CHILDREN: 0CENSUS: 172DATE:
06/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:45 AM
MET WITH:Autumn Conquest, Assistant Executive Director
Ito Chong, Assited Living Director		TIME VISIT/
INSPECTION COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by receptionist. LPA met with Autumn Conquest, Assistant Executive Director and Ito Chong, Assisted Living Director and explained the nature of the visit. Facility is licensed for 230 non-ambulatory residents, approved for secured perimeters, and delayed egress. Facility has an approved hospice waiver for 20 residents. The facilities current census is 172 residents. There are 10 residents on hospice during today's visit. This facility consists of two main areas. The assisted living and the memory care unit which are protected by delayed egress exits.

LPA Martinez along with staff toured the physical plant of both the assisted living and the memory care unit. LPA observed a bistro adjacent to the main dining room where residents can obtain different snacks and beverages selections than in the main dining area. The bistro offers snacks all day so residents may dine when convenient. LPA observed menus for both areas and the food offered is varied and healthful. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Maintenance records were observed in the main kitchen. Facility has two food vendors that deliver food supplies. One of the vendors delivers once a week, where as the other vendor delivers twice a week. During the tour LPA observed residents involved in an activity as well as a posted activity schedule including games, exercise, and outings at the facility. LPA inspected that medication is centrally stored in a safe locked location; facility has a medication room and use medication carts to distribute medication to residents. LPA observed and inspected medication carts that are used to dispense meds to residents and observed

Continued on LIC809-C

Armando J LuceroTELEPHONE: (949) 430-1222
Ruth MartinezTELEPHONE: (657) 285-1397
DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 TERRACE
FACILITY NUMBER: 306001157
VISIT DATE: 06/16/2025
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medication was labeled and stored inaccessible to residents in care. Ten resident bedrooms were inspected in combination of assisted living and memory care unit and observed to have the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Resident bathrooms were inspected tested for water temperature and water temperature measured between 115.9 to 117.5 degrees F in tested bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Call buttons were observed in each resident apartments and when pulled a signal is sent to caregivers pagers and front receptionist as backup and accuracy for answering the call. LPA tested the pull cord system and observed it to be working properly. LPA observed several residents who appeared clean, and happy. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored locked in a locked storage closet. LPA toured the memory care unit and observed a kitchen/ dining room as well as posted activity schedule for memory care residents. LPA observed residents in the memory care unit with care staff present. LPA observed the delayed egress exits and observed for proper functioning. LPA observed smoke/carbon monoxide detectors and sprinkler system. Fire extinguishers are fully charged and were observed to be mounted on the wall throughout the facility. Smoke detectors, sprinkler system, and fire extinguishers are tested yearly by an outside agency, and LPA verified last testing was done January 10, 2025 for the sprinkles and February 7, 2025 for the smoke/carbon monoxide detectors. Emergency drills are being conducted quarterly, LPA verified facility has a fire drill log. Outside grounds have ample shaded seating for residents in both assisted living and memory care unit. LPA observed a swimming pool in the outside perimeters of the assisted living side with a fence around it. LPA observed the pool gate that has a self-latching entry door which opens away from the pool. The fence has a key lock at the gate door for inaccessibility. LPA measured the pool fence which measured 5ft 10in from base of the floor to the top of the fence and it was observed to enclose the entire pool area. LPA reviewed 10 resident files and five staff files. All resident files contained required documentation including updated physician reports and care plans. Staff files contained required documentation including health screens, first aid, and fingerprint clearance.

Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.



This report was reviewed with the facility representatives and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
LIC809 (FAS) - (06/04)
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