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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005798
Report Date: 12/12/2022
Date Signed: 12/12/2022 02:17:34 PM


Document Has Been Signed on 12/12/2022 02:17 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 ESTATESFACILITY NUMBER:
306005798
ADMINISTRATOR:HEATHER MYERSFACILITY TYPE:
740
ADDRESS:11360 WARNER AVE.TELEPHONE:
(949) 333-3486
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:150CENSUS: 121DATE:
12/12/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:06 PM
MET WITH:Robert Jakini, Executive DirectorTIME COMPLETED:
02:20 PM
NARRATIVE
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On today's date, Licensing Program Analysts (LPAs) Rosie Quiroz and Alvaro Ramirez made an unannounced case management visit in conjunction with the following Complaint Control Numbers: 22-AS-20221205140654 and 22-AS-20221207111938.

During today's visit, LPAs were greeted, COVID screened and granted entry by Front desk concierge and Executive Director (ED) Robert Jakini.

The purpose of today's visit was to conduct interviews for complaint control numbers identified above. As LPAs Quiroz and Ramirez were walking down North/South hallway, Luis Serrano, Chief Executive Officer (CEO) approached LPAs Quiroz and Ramirez admitting to listening to private interview with Staff 1 (S1).

LPA Quiroz reminded CEO Serrano of importance of allowing private setting for interviews.

A Citation was issued per Title 22 Division 6 of the California Code of Regulations- 87755(b): Inspection Authority of the Licensing Agency(b):The licensee shall ensure that provisions are made for private interviews with any resident or any staff member; and for the examination of all records relating to the operation of the facility.

LPAs Rosie Quiroz and Alvaro Ramirez conducted an exit interview with (ED) Robert Jakini and provided (ED) Jakini with a copy of this report, regulation discussed, LIC 811-Confidential Names, LIC809-D and Appeal Rights at exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 12/12/2022 02:17 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: 12/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied: Appeal Not Submitted Timely
Type B
12/16/2022
Section Cited
CCR
87755(b)

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87755(b):Inspection Authority of the Licensing Agency(b) The licensee shall ensure that provisions are made for private interviews with any resident or any staff member;... facility. This requirement was not met as evidenced by: CONTINUED BELOW
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CEO Serrano and ED Jakini will review regulation 87755(b) and submit proof of understanding CCR 87755(b) by POC Due date of 12/16/2022. CEO and ED will ensure privacy while conducting interviews with residents or staff members and not retaliate to staff or residents. CONT BELOW...
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Baed on interview conducted with Luis Serrano, Chief Executive Officer (CEO). CEO Serrano approached LPAs Quiroz and Ramirez admitting to listening to private interview with Staff 1 (S1).
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In the future, if interview conversations are overheard CEO and or/ED will notify LPA/LPAs.

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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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2