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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005798
Report Date: 09/11/2023
Date Signed: 09/11/2023 01:53:51 PM


Document Has Been Signed on 09/11/2023 01:53 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:PARK VIEW ESTATESFACILITY NUMBER:
306005798
ADMINISTRATOR:ROBERT A. JAKINIFACILITY TYPE:
740
ADDRESS:11360 WARNER AVE.TELEPHONE:
(949) 333-3486
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:150CENSUS: 109DATE:
09/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 AM
MET WITH:Dawn BlankenshipTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Ruth Martinez made visit to this facility to conduct a case management visit. LPA arrived at facility was greeted and granted entry by receptionist. LPA met with Dawn Blankenship, Regional Director of Operations and explained the nature of the visit.

LPA is conducting this visit as a follow up on an incident that was self reported an on September 07, 2023 regarding R1’s incident on September 06, 2023.

During today’s visit, LPA interviewed staff and copies pertinent documents will be email to LPA.

On September 06, 2023 at approximately 11:30am staff went to residents bedroom to help with ADL's and radioed for staff to send in assistance. R1 was found laying in the bathroom. Staff immediately assessed R1 and determined that 911 had to be called. Paramedics arrived to the facility assessed R1 and was sent to hospital for evolution. R1 still remains at hospital for observation. Facility notified R1's responsible party and primary care physician. Facility does not have an estimated date when resident will be discharged from hospital. LPA did not observe any immediate and/or safety risks in or out of the facility.

This report was reviewed with facility representative and a copy of the report was provided and left at the facility.

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2023
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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