306001157-6-14-2022-22-AS-MVAO-CG9PDN-20220712111348

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306001157
Report Date: 06/14/2022
Date Signed: 06/14/2022 11:09:36 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/23/2020 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20201123165950

FACILITY NAME:	PARK TERRACE		FACILITY NUMBER:	306001157
ADMINISTRATOR:	KOEHLER, EUGENE (GENO)		FACILITY TYPE:	740
ADDRESS:	21952 BUENA SUERTE		TELEPHONE:	(949) 888-2250
CITY:	RANCHO SANTA MARGARI	STATE: CA	ZIP CODE:	92688
CAPACITY:	230	CENSUS: 167	DATE:	06/14/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Geno Koehler		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

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-Staff did not adequately supervise resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegation. LPA arrive at facility was greeted by receptionist and granted entry. LPA spoke with Geno Koehler, Administrator and explained the purpose of the visit.

Findings are based upon this investigation which included virtual tour of the memory care unit, file review and interview conducted.
It is alleged that staff did not adequately supervise resident. In review of R1’s file it is indicated that resident resides in the memory care unit of the facility. The facilities memory care unit has its own courtyard for the resident’s enjoyment. Facility staff schedule indicates that there are three shifts for caregivers being 6:30am – 2:30pm, 2:30pm – 10:30pm and 10:15pm – 6:30am. With having anywhere of 3 – 6 caregivers per shift.

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022

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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Control Number 22-AS-20201123165950

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: PARK TERRACE	FACILITY NUMBER: 306001157
	VISIT DATE: 06/14/2022

NARRATIVE

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Interview conducted with Administrator revealed that R1 wanted to go and enjoy the courtyard of the memory care unit and staff took R1 to the courtyard. Staff were on site monitoring R1. As part of memory care unit resident’s area allowed to walk around the unit as well as the courtyard of the unit. The perimeters exit and entry ways are secured with egress doors with alarms. Facility doors use an electric magnetic lock that can only be access by staff. Upon the case if a resident leaves the memory care unit immediately the alert alarm will sound alerting staff of an unauthorized exit of the unit. Based on the information received from interviews, the lack of information regarding individual in question, and the lack of corroborating witnesses, LPA is unable to determine if the alleged violation occurred as reported.

Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

An exit interview was conducted with Administrator and a copy of this LIC9099 report was left at facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022

LIC9099 (FAS) - (06/04)

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