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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001157
Report Date: 05/31/2022
Date Signed: 05/31/2022 12:38:25 PM


Document Has Been Signed on 05/31/2022 12:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 167DATE:
05/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Geno KoehlerTIME COMPLETED:
12:50 PM
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Licensing Program Analysts (LPAs) Jessica Cho and Edward Tapia conducted an unannounced required annual inspection in this facility focusing primarily on the Infection Control. LPAs were greeted and granted entry by Executive Director/Administrator (Admin) Geno Koehler after completing the Coronavirus 2019 (COVID-19) screening procedure. Facility screens and documents temperature for all staff and visitors electronically. The PUB475 See Something, Say Something poster was observed in the size of 11"x14" by the front desk. LPAs did not observe the required Department postings as they were currently being replaced. The Administrator's Certificate for Geno Koehler expires on 7/22/2022.

Around 9:38 am, LPAs toured the interior and exterior portions of the facility with Admin Koehler. The facility is a two level structure and licensed for two hundred thirty non-ambulatory residents; approved for secured perimeter and delayed egress; and has a hospice waiver for twenty residents. Currently, there are one hundred and sixty seven residents and fourteen out of the one hundred sixty seven are in hospice care as of today. Facility appeared clean and sanitary in all areas observed. LPAs inspected sixteen randomly selected rooms total- eight on each floor and observed the following: all sixteen rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke, carbon monoxide, and auditory exit alarms tested operational. The bathrooms were observed to be in good repair except in Apartments #141, #145, and #259 as a single light bulb in each of the bathrooms needed to be replaced. All bathrooms were provided with grab bars and non-skid floor mats, and hot water measured between the ranges of 109.5 to 116.6 degrees Fahrenheit. LPAs observed hand washing signs in the community bathrooms but none in the resident's bathrooms. Facility had hand sanitizers mounted on the wall throughout the facility and in the common areas. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies, and sharp items were inaccessible to the residents in care. Fire extinguishers were mounted and charged. For the exterior portion, LPAs observed patio furniture under a gazebo in the courtyard, and the grounds were free of tripping hazards.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PARK TERRACE
FACILITY NUMBER: 306001157
VISIT DATE: 05/31/2022
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LPAs observed the emergency disaster and evacuation plans. Facility had back-up emergency food and water supply. The First Aid Kits had all the required components, and the facility had sufficient PPEs and incontinence supplies. Facility has a plan for COVID-19 testing residents and staff as well as a plan for isolation as needed.

LPAs consulted the following: to post COVID-19 precautionary signs by the front entrance, to enlarge the PUB475 See Something, Say Something poster in the size of 20"26," to repair the broken light bulbs in Apts #141, #145, and #259, to repair the grab bar in the elevator, and to post hand washing signs in all resident's bathrooms.

LPA discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. Residents have access to seven tablets provided by the facility.



LPA reviewed the COVID-19 mitigation plan of the facility. No deficiency cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit, and the Administrator will follow-up with the corrections. An exit interview was conducted with Administrator Geno Koehler, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022
LIC809 (FAS) - (06/04)
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