306005798-2-22-2022-22-AS-PVEZ-CBVVYG-20220222155108

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005798
Report Date: 02/22/2022
Date Signed: 02/22/2022 03:51:16 PM

Document Has Been Signed on 02/22/2022 03:51 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 VIEW ESTATES		FACILITY NUMBER:	306005798
ADMINISTRATOR:	HEATHER MYERS		FACILITY TYPE:	740
ADDRESS:	11360 WARNER AVE.		TELEPHONE:	(949) 333-3486
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	150	CENSUS: 65	DATE:	02/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Richard Mariona - Health Services Director		TIME COMPLETED:	04:10 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	Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to Park View Estates. The purpose of today's visit was to conduct a Required 1 Year inspection. LPA Velazquez was allowed entry into the facility and met with Health Services Director (HSD) Richard Mariona. The facility is licensed for 150 non-ambulatory residents of which 44 residents may be bedridden. The facility also has a hospice waiver for 10 residents. LPA was provided with a copy of the most recent Fire inspection which was conducted on February 8, 2022. LPA was also provided with a copy of the most recent liability insurance via email. At 1:10 PM LPA Velazquez conducted a tour of the physical plant along with HSD Mariona. The facility consists of 2 stories with 150 resident rooms each with their own or shared bathrooms. There are 3 activity rooms, 2 movie theaters, 2 dining rooms, kitchen, 2 hair salons, memory care area, a library/game room, a sensory spa, 3 courtyards, a lobby area and a bistro. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. LPA Velazquez observed a postural support bar on one of the resident beds. Resident bath towels and personal hygiene supplies were adequately stocked. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew and a non-skid surface was in place. LPA Velazquez tested the hot water temperature in 10 resident bathrooms and the temperature ranged from 125.2 degrees Fahrenheit to 138.0 degrees Fahrenheit verified by HSD Mariona. LPA Velazquez immediately informed HSD that maintenance should be contacted to lower the water temperature. HSD immediately contacted maintenance who began addressing this issue. LPA Velazquez inspected the kitchen along with HSD Mariona. Perishable and non-perishable food supply was checked and adequately stocked at the time of the visit. Emergency food supply was also adequately stocked. Fire Extinguishers throughout the facility were

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2022

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 VIEW ESTATES	FACILITY NUMBER: 306005798
	VISIT DATE: 02/22/2022

NARRATIVE

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fully charged. Toxins, sharps, and medications were locked and inaccessible to residents in the Memory Care area of the facility. The delayed egress doors were tested and found operational. First Aid kit was checked and found to be in order. The facility had a First Aid guide and LPA Velazquez advised HSD Mariona to obtain an updated First Aid manual.

LPA Velazquez along with HSD Mariona toured the outside grounds and no bodies of water were observed. There was shading and sufficient seating for residents. Walkways around the facility were clear of hazards There were no security bars or weapons on the premises.

No resident or staff files were reviewed at the time of this visit. LPA Velazquez informed HSD Mariona to ensure a written physician's order for the postural support bar is present in a resident's file pursuant to Title 22 Regulation Section 87608 Postural Supports. HSD indicated he would review the resident's file to ensure it contained the required documentation.

Deficiencies cited under California Code of Regulations Title 22, Division 6, Chapter 8. An exit interview was conducted with HSD Richard Mariona and a copy of this report along with the appeal rights and a copy of the LIC 9098 were provided at the time of this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/22/2022 03:51 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

873039E)(2) Maintenance and Operation. Water supplies and plumbling fixtures shall be maintained as follows: Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 10 out of 10 resident rooms which poses an immediate health, safety or personal rights risk to persons in care. The hot water measured ranged from 125.2 degrees Fahrenheit to 138.0 degrees Fahrenheit which was verified by HSD Mariona.
	POC Due Date: 02/22/2022
	Plan of Correction
1 2 3 4	Licensee to ensure the hot water temperatiure is maintained pursuant to regulation and submit written proof to LPA Velazquez by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2022

LIC809 (FAS) - (06/04)

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