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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001157
Report Date: 02/03/2025
Date Signed: 02/03/2025 11:08:12 AM

Document Has Been Signed on 02/03/2025 11:08 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/
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: 176DATE:
02/03/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Ito Chong, Assisted Living DirectorTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
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This unannounced case management visit is being conducted by Licensing Program Analysts (LPAs) Ruth Martinez and Hanna Gough to follow up on an incident reported to Community Care Licensing. LPAs arrived at facility was greeted by receptionist and granted entry. LPAs met with facility representative and explained the purpose of today’s visit. Incidents were self-reported on January 27, 2025, regarding resident (R1’s) incidents on January 22, 2025.

During today’s visit, LPA Martinez interviewed staff, completed resident file review, and obtained copies of pertinent documents.

On January 22, 2025, R1 was in their apartment sweeping their kitchen when they lost their balance and fell. R1 was an independent resident and did not get any assistance while at the facility. Since R1 was an independent resident, they do not require to have a pendent unless they choose to have one. R1’s daughter was at the community and decided to take the resident to the hospital. Upon stay at the hospital it was determined that R1 now needed assistance and decided to move out R1 to a smaller board and care facility and notified facility that resident was moving out and not returning to the facility.

LPAs found that facility acted appropriately and in a timely manner to address the incident and all other immediate attention to injuries in question. LPAs did not observe any immediate and/or safety risks in or out of the facility.

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

This report was reviewed with facility representative, and a copy of the report was furnished to the facility.

Armando J LuceroTELEPHONE: (949) 430-1222
Ruth MartinezTELEPHONE: (657) 285-1397
DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2025
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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