306005798-5-6-2024-22-AS-RQUZ-D4ZVMM-20240506163343

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005798
Report Date: 05/06/2024
Date Signed: 05/06/2024 04:34:31 PM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/06/2024 04:34 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:	ROBERT A. JAKINI		FACILITY TYPE:	740
ADDRESS:	11360 WARNER AVE.		TELEPHONE:	(949) 333-3486
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	150	CENSUS: 111	DATE:	05/06/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:31 AM
MET WITH:	Cauleen Ritchie, Regional Clinical Specialist, Peggy Ulland, Interim Director, Jamie Pyles, Health and Wellness Director and Dawn Blankenship, Regional Director of Operations		TIME COMPLETED:	04:35 PM

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On today’s date, Licensing Program Analyst (LPA) Rosie Quiroz conducted a subsequent Annual Required visit after conducting a 10-day visit for complaint control #22-AS-20240501091507. LPA was greeted and met with Cauleen Ritchie, Regional Clinical Specialist (RCS), Peggy Ulland, Interim Director (ID), Jamie Pyles, Health and Wellness Director (HWD) and discussed purpose of today's visit. Dawn Blankenship, Regional Director of Operations (RDO) arrived during today's visit.

Administrator (AD) Maria Arriaga has an Administrator certificate with expiration date of November 7, 2024.

The facility is licensed to provide services to residents age range 60 and over. Approved for 150 (One hundred and fifty) Non-Ambulatory residents of which 44 (forty-four) may be bedridden. Approved Hospice Waiver for 15 (fifteen) residents. There are currently 12 (twelve) residents receiving hospice care services.

Between 10:57am-1:55pm, LPA Quiroz along with (ID) Ulland and (HWD) Pyles toured the interior and exterior of facility premises consisting of memory care unit and Assisted Living area. During and after the inspection tour, LPA Quiroz conducted interviews with residents and staff.

The required two (2) day perishable and seven (7) day non-perishable food supply was observed. Toxic substances were locked and inaccessible to residents in care. LPA observed cooking areas to be maintained with cleanliness. LPA observed facility refrigerator and freezer to be operational and met regulatory requirements. Resident's bathrooms were observed to have working sinks, faucets and flushing toilets. LPA tested hot water temperatures which ranged between 107.0 degrees- 114.0 degrees Fahrenheit. Grab bars and non-skid mats were also observed in resident bathrooms. Personal hygiene items for resident use were observed in each bathroom. LPA observed all resident rooms to have required linens, furnishings, and adequate lighting. All linens and furnishings were clean and in good repair. The medications were inaccessible to residents in care, centrally stored and maintained in compliance. All pathways, doorways, and emergency exits were observed to be free of obstruction. (CONTINUED ON LIC 809 C)

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024

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: 05/06/2024

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CONTINUED...There were no bodies of water observed anywhere on the property. PPE stored in storage area on the second floor next to the medication room area.

Between 2:05-3:30pm, LPA Quiroz reviewed ten (10) resident files and ten (10) personnel files. The residents and staff files were found to be in compliance.

LPA observed staff answer facility telephone which verified a working telephone was maintained at the facility. Regulatory required postings were observed to be posted in the lobby area. Facility was operating within the allowed capacity. Fire extinguishers were charged, mounted throughout the facility and last serviced on April 30, 2024. Facility indicated Pest Control services facility monthly or as needed and last serviced on April 10, 2024. LPA verified that fire/disaster drills are conducted at least quarterly and on each shift by Maintenance/Safety Director. Last fire drill was conducted on May 2, 2024. The Emergency exit plans were posted and available for reference throughout the facility. Residents were accorded clean and comfortable accommodations.

Based on the observations made during today’s visit, no citations were issued during today's visit. An exit interview was conducted with (ID) Peggy Ulland and (HWD) Pyles. A copy of today's report, LIC 858 and LIC 859 pages were provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024

LIC809 (FAS) - (06/04)

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