306001157-4-30-2025-22-AS-AJLO-DGESFS-20250506135048

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306001157
Report Date: 04/30/2025
Date Signed: 04/30/2025 10:16:41 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
01/14/2025 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20250114115805

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: 184	DATE:	04/30/2025
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Geno Koehler		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Facility physically abused resident.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Ruth Martinez and Hanna Gough conducted an unannounced visit to the facility to deliver findings related to the investigation of the complaint allegation identified above. Upon arrival, LPAs were greeted by facility staff and granted entry. LPAs met with Geno Koehler, Executive Director, and explained the purpose of the visit.

The findings are based on an investigation that included a review of the resident’s file, a physical plant tour of the facility, and interviews with relevant staff and residents.

The complaint alleged that Resident 1 (R1) had unexplained bruising and had experienced a fall. Resident file review revealed the following: Care plans dated February 16, 2024, and March 18, 2024, indicate that R1

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: 04/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025

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-20250114115805

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: 04/30/2025

NARRATIVE

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uses a walker for mobility and a wheelchair for longer distances. Transfers are generally minimal and staff may assist as needed. R1 requires staff supervision and occasional assistance during mobility, and there is no known or reported history of falls. Staff are instructed to observe and report any changes in gait or balance. A care plan dated September 20, 2024, notes that R1 requires mobility escort to and from meals and common areas, minimal assistance for transfers, and supervision to ensure safety. Safety checks are conducted four times per night during the NOC shift. Again, no history of falls was reported at that time. A resident assessment dated February 7, 2024, indicates that R1 uses a pendant call system, requires wheelchair escorts, and uses a walker. It also notes that R1 had a fall approximately 1.5 years ago while attempting to dispose of recycling.

Staff interviews (3 of 3) revealed that staff became aware of the recent fall after observing bruising on R1. R1 reportedly stated they had fallen but could not recall specific details. Resident interview confirmed that R1 fell while attempting to get up from a recliner and lost balance. R1 also stated they did not report the fall to staff at the time.

Based on the information gathered during the investigation, interviews and review of all documents obtained, 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.

This report was reviewed with Executive Director and a copy was furnished to 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: 04/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025

LIC9099 (FAS) - (06/04)

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