306001157-12-27-2023-22-AS-SSAS-CYY2ZA-20231228165001

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306001157
Report Date: 12/27/2023
Date Signed: 12/27/2023 10:40:56 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
09/15/2021 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210915083957

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: 162	DATE:	12/27/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Ito Chong		TIME COMPLETED:	11:10 AM

ALLEGATION(S):

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-Residents need a higher level of care

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 arrived at the facility and was greeted by front office staff and granted entry. LPA spoke with Ito Chong, Assisted Living Director and explained the purpose of the visit.

Based on the information obtained during this investigation the department has concluded the investigation into the above mentioned allegation. Findings are based upon this investigation which include interviews conducted, tour of physical plant of facility and copy of pertinent documents obtained. It is alleged residents need a higher level of care. Interviews with 2 of 2 staff revealed that there are no concerns for any resident in care that may need a higher level of care. The facility indicated that there have been residents that have been reassessed and there was no indication that those residents needed a higher level of care. Residents were reassessed due to caregivers indicating a concern that they may need a higher level of care. Interviews

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

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-20210915083957

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/27/2023

NARRATIVE

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conducted with 2 of 4 residents in care revealed that they felt that they get the care they need, they always have a two caregiver assistance, they get the physical therapy that is needed, and they get assistance when requested. Residents indicated that they had no concerns with their care and felt they were getting the care that they needed. Records review indicated that resident (R1) care plan 1 person assists with showers, 2 persons assist with transfers and is on level 4 care plan. Resident (R2) care plan indicates they need med assistance, escorting, 4 safety checks per shift and is on level 4 care plan. Resident (R3) care plan indicates that resident requires 1 person assist, escort resident as needed, 2 persons transfer assist and is on level 4 care plan. Resident (R4) log indicates that they get repositions every 2 hours, 2 persons assist transfer and is a care plan level 3. There were no indications that residents required a higher level of care or care that the facility could not provide.

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 facility representative and a copy of this LIC9099 report was left at the facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC9099 (FAS) - (06/04)

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