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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001157
Report Date: 06/12/2024
Date Signed: 06/12/2024 11:51:04 AM


Document Has Been Signed on 06/12/2024 11:51 AM - 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:KOEHLER, EUGENE (GENO)FACILITY TYPE:
740
ADDRESS:21952 BUENA SUERTETELEPHONE:
(949) 888-2250
CITY:RANCHO SANTA MARGARISTATE: CAZIP CODE:
92688
CAPACITY:230CENSUS: 168DATE:
06/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Geno KoehlerTIME COMPLETED:
12:10 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 Geno Kohler, Executive 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 168 residents. There are 15 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 Executive Director 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. 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. LPA observed and inspected medication carts that are used to dispense meds to residents and observed medication was labeled and stored inaccessible to residents in care. Eight resident bedrooms were inspected 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 117.6 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

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
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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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: 06/12/2024
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and front receptionist as backup and accuracy for answering the call. 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 had a service date of June 10, 2024. Smoke detectors, sprinkler system, and fire extinguishers are tested yearly by an outside agency, and LPA verified last testing was done June 10, 2024. Emergency drills are being conducted quarterly. 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 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 four 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. LPA as a reminder provided annual fee dues information.

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 Executive Director 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: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC809 (FAS) - (06/04)
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