306005798-1-6-2021-22-AS-MBAT-BWZTKB-20210106134739

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005798
Report Date: 01/06/2021
Date Signed: 01/06/2021 01:49:59 PM

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 VIEW ESTATES		FACILITY NUMBER:	306005798
ADMINISTRATOR:	HUNDLEY, SHANNON		FACILITY TYPE:	740
ADDRESS:	11360 WARNER AVE.		TELEPHONE:	(949) 333-3486
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	150	CENSUS: 0	DATE:	01/06/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Executive Director (ED) Shannon Hundley		TIME COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At 10:15 AM, Licensing Program Analyst (LPA), Mike Barrett contacted the facility via telephone for the purpose of conducting a pre-licensing inspection due to COVID 19 and pre-cautionary measures and met with Executive Director (ED) Shannon Hundley. This facility is comprised of a dual story building for the Assisted Living units and a single story section where memory care residents are planned to reside. LPA Barrett's observations during the physical plant inspection were as follows: Structure: Facility is a, newly constructed, two-story structure with a capacity to house 111 Assisted living residents and 39 Memory Care residents in the memory care unit, which is located on the first floor and contains was observed to be equipped with two delayed egress doors entrances/exit which were tested and observed to be in good operation. LPA toured the interior and exterior of the facility with ED Hundley which included units 107, 118, 119, 221, 218 and 224 of the assisted living sections and units 180 and 193 in the memory care unit. Signal system: Signal system consist of alert pull chords in the unit bathrooms located on the wall adjacent to the toilet as well as in the bedroom area of the unit for bedside use. The residents will be given alert pendants that will be worn at all times that, when activated, will notify staff on PDA devices which notify the staff of resident and location. Bedrooms for Residents: Bedrooms were unfurnished and equipped with kitchenettes, containing refrigerators/freezers and microwaves. Each unit was observed to have canned ceiling lights as well as smoke detectors and sprinklers in each room. Rooms were unfurnished, window screens were in good repair and the units were clean. Continued on page 2.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael Barrett	TELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2021

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 VIEW ESTATES	FACILITY NUMBER: 306005798
	VISIT DATE: 01/06/2021

NARRATIVE

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Continued from page 1.
Bathrooms:
Each unit was equipped with private bathrooms that were equipped with grab bars by the toilets and in the shower stalls. The showers had a built-in foldable chair, lighting and non-skid mats. Toilets, shower head and faucets were observed to be clean and in good repair.
Hallways and stairwells:
The hallways were clean and observed to be free of obstructions. The facility had three (3) emergency stairwells that were clear of obstructions and equipped with the required emergency stairwell chairs at the top level of the stairwell. LPA observed and inspected eight (7) fire extinguishers in the hallways that were observed to be properly mounted and appropriately charged.
Amenities and Common Areas:
The facility had several common areas including a lobby sitting area and bistro. LPA observed several seating areas throughout the facility as well as activity rooms and an exercise room. There were Two (2) courtyards, one located in the center of the the assisted living units and the other in the center of the memory care unit, that were equipped with shaded seating and paved walkways. The walkways were observed to be free of obstructions.
Kitchen and Food Service:
LPA toured the kitchen and inspected the walk in refrigerator, freezer, dishwashers and sanitation stations, temperature logs, food prep areas, fire extinguishers, wash basins, and dry goods storage. LPA observed that the facility did not have a large stock of food due to there were no residents residing in the facility at the time of this inspection. LPA and ED discussed the 7 day non perishable and 2 day perishable food supply regulation. The kitchen was clean and in good order, temperatures for the refrigerator and freezer were within regulation, temperature logs were completed and the fire extinguishers were properly mounted and appropriately charged.
Medication room:
The facility had two medication rooms, one in the Assisted living unit and the other in the memory care unit, that were equipped with nurses stations. The medication rooms were locked and inaccessible to residents. In the rooms were medication carts, refrigerators and locked cabinets for the storage of medications and medical files. There were no residents in the facility and therefore no medication were observed or reviewed.

Continued on Page 3.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael Barrett	TELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

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 VIEW ESTATES	FACILITY NUMBER: 306005798
	VISIT DATE: 01/06/2021

NARRATIVE

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Continued from page 2.
Smoke Detectors:
Smoke detectors were located in each living unit and in throughout the common areas of the facility. The carbon monoxide detectors was located in the resident hallways and common areas throughout the facility and were observed to be operational.
Fire Clearance:
Fire clearance was granted for 106 non-ambulatory and 44 bedridden residents.
Water Temperature:
Water temperatures were measured in the units listed above and were as follows: 106.0, 107.5, 106.5, 107.5, 105.5 and 107.0 degrees Fahrenheit in the assisted living units and 106.0 and 107.5 degrees Fahrenheit in the memory care units.
Activities:
The facility had an exercise room with some exercise equipment as well as an activity room. LPA observed the activities plan posted on an information wall.
Signs:
LPA discussed the requirement for signs to be posted throughout the facility promoting social distancing, hand washing, symptoms reporting. LPA observed Ombudsman contact information, Let-Us-No, Resident Personal Rights, Resident Council, Theft and Loss policy and emergency phone numbers were posted as required.

The Component III Orientation was waived due to the Executive Director's work history in other facilities in the same role. LPA and ED discussed the reporting requirements, COVID-19 precautionary measures and guidelines as well as .

This facility's physical plant meets requirement of Title 22 regulations and LPA has recommended the facility for licensure.

The pre-licensing inspection has been completed. License will be granted upon approval by the Central Application Bureau (CAB). An exit interview was conducted and a copy of this report was provided to Executive Director (ED) Shannon Hundley via email with instructions to sign and scan a copy of this report to LPA Barrett.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael Barrett	TELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2021

LIC809 (FAS) - (06/04)

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