306001157-6-14-2022-22-AS-MVAO-CG9P2G-20220712105553

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306001157
Report Date: 06/14/2022
Date Signed: 06/14/2022 10:39:10 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
07/16/2020 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200716134339

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:	09:30 AM
MET WITH:	Geno Koehler		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

-Staff are limiting residents activities while in care

-Staff are delaying residents from accessing timely medical care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegations. LPA arrive at facility was greeted by the 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 facility file review, covid-19 protocol notices, and interview conducted.
It is alleged that staff are limiting residents’ activities while in care and staff are delaying residents from accessing timely medical care. Per review of notices sent to residents, associates and family member indicate that facility was following covid-19 protocol from Department PIN’s. Upon review of facility records it is indicating that facility was following PIN 20-07-ASC dated March 13, 2020 and PIN 20-23-ASC dated

Continued 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)

Page: 1 of 2

Control Number 22-AS-20200716134339

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

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
26
27
28
29
30
31
32

June 26, 2020. Per interview with Administrator revealed that facility allowed residents to leave the facility as needed for appointments and required to get tested upon return. Residents were asked to self isolate while Covid test results are returned as a recommendation. If residents’ doctors were not scheduling in person visit facility had set up two rooms for tele health visit. If in the case resident was not able to go to the designated rooms a tablet was taken to the resident’s apartment in order to accommodate to the residents. The fitness center remained open by appointment only. Classes were also available to groups of 10 or less in order to follow social distancing amongst residents. Which correlates with PIN 20-07-ASC and PIN 20-23-ASC.

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)

Page: 2 of 2