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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306001157
Report Date: 05/19/2025
Date Signed: 05/19/2025 09:50:42 AM

Substantiated


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
04/10/2025 and conducted by Evaluator Ruth Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250410123109
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: 169DATE:
05/19/2025
UNANNOUNCEDTIME BEGAN:
07:40 AM
MET WITH:Autumn Conquest, Assistant Executive DirectorTIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Staff gave resident another resident's medication
Staff did not involve resident in the care plan
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to deliver findings related to the investigation of the complaint allegations identified above. Upon arrival, LPA was greeted by facility staff and granted entry. LPA met with Autumn Conquest, Assistant 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 staff gave resident another resident’s medication. Interview with staff 1 (S1) stated that Resident 1 (R1) had been given resident 2 (R2) medication on April 05, 2025, and notified the

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
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 5
Control Number 22-AS-20250410123109
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: 05/19/2025
NARRATIVE
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department on April 06, 2025, of the medication error. Record review reflects that R1 was given R2’s medication the night of April 5, 2025, and R1 had no adverse reaction to the medication.

The complaint alleged that staff did not involve resident in the care plan. Review of resident’s records revealed that R1 move in the facility on September 22, 2024. A care plan dated September 24, 2024, reflect on page 3 document to be signed only by the community, residents and/or family/responsible party/POA is missing. Care plan dated October 28, 2024, reflect on page 3 no signature from any parties. Records for care plan reflect a care plan with no effective date but signature page reflects September 21, 2024, with an electronic signature for both community and resident. Interview with R1 stated that they did not attend any of the care plan meetings and have not signed any documents because of this.

Based on the information gathered the preponderance of evidence standard has been met, therefore, the allegations, facility gave resident wrong medication and resident was not involved with care plan are found to be SUBSTANTIATED.

Based on this inspection, deficiencies were observed at this time in the areas evaluated per Title 22 Division 6 Chapter 8 of the California Code of Regulations. See LIC9099-D for deficiencies.

This report was reviewed with facility representative and a copy of this LIC9099, LIC9099-D report was provided and left at facility. Appeal rights reviewed, and a copy provided.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20250410123109
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/02/2025
Section Cited
CCR
87465(a)(4)
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(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist resident with self-administered
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Executive Director will provide additional training to all Medication Technicians and submit proof to LPA by POC due date.
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medications as needed. This requirement was not met as evidenced by: Based on interview and documents, the licensee did not ensure R1 received assistance with self-administered medications due to a medication error, which posed a potential health risk to persons in care.
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Type B
06/02/2025
Section Cited
CCR
87467(a)
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(a) Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, and any other appropriate parties, to prepare
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Executive Director will complete the residents care plan with resident and/or resident's responsible party's input and approval, completed and signed. Executive Director will send a signed copy of the care plan and written plan to LPA in the event residents refuse to sign by POC date.
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a written record of the care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility. This requirement was not met as evidenced by: Based on interview and documents, the licensee does not have a signed care plan by resident.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
04/10/2025 and conducted by Evaluator Ruth Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250410123109

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: 169DATE:
05/19/2025
UNANNOUNCEDTIME BEGAN:
07:40 AM
MET WITH:Autumn Conquest, Assistant Executive Director TIME COMPLETED:
10:20 AM
ALLEGATION(S):
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9
Staff did not do a proper assessment with change in condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to deliver findings related to the investigation of the complaint allegations identified above. Upon arrival, LPA was greeted by facility staff and granted entry. LPA met with Autumn Conquest, Assistant 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 staff did not do a proper assessment with change of condition specifically with being able to leave the facility unassisted. Records review revealed that resident 1 (R1) move into the facility on September 22, 2024, and LIC602 physician’s report dated September 11, 2024, page 3 number 14m

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20250410123109
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: 05/19/2025
NARRATIVE
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states able to leave community unassisted is marked no and furthermore stated patient cannot leave unassisted due to MCI. Physician’s report dated October 9, 2024, page 3 number 14m states able to leave community unassisted is marked no. Interview with 2 of 2 staff stated that R1 did not have a change of condition upon admissions to the facility R1’s physician’s report stated R1 could not leave the facility unassisted and R1 did not agree with the information that was provided. Staff stated they have not observed any incidents that would indicate that R1 has had a change of condition.

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 facility representative and a copy was furnished to the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5