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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005798
Report Date: 03/22/2022
Date Signed: 03/22/2022 02:17:37 PM


Document Has Been Signed on 03/22/2022 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: 71DATE:
03/22/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:54 PM
MET WITH:Heather Myers, Executive Director, Richard Mariona, Health Services DirectorTIME COMPLETED:
02:25 PM
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 On today’s date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit for the purpose of conducting a case management deficiency. LPA was greeted and met with Administrator Heather Myers and Richard Mariona, Health Services Director.

During the course of complaint investigation, control number 22-AS-20211005172231, the following deficiencies were observed: Staff 1 (S1) was observed to not be associated to the facility despite being on site more than three days per week and/or 16 hours per week.

Required personnel paperwork for (S1) was observed not to be retained on file at facility as S1 was hired through a temp agency. Facility failed to request copies of pertinent documents to retain on site.

Following R1’s fall on 9/30/2021 and continuous yelling in pain, facility staff did not call 9-1-1 and/or notify R1’s physician of fall and change in condition.

The following is being cited per Title 22, Division 6 of the California Code of Regulations. Civil Penalty assessed during today's visit.

An exit interview was conducted with Administrator Heather Myers and Richard Mariona, and a copy of this report, along with LIC9099-D, LIC 421IM, Appeal Rights, and the LIC 811, identifying confidential names were provided at exit.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022
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 3


Document Has Been Signed on 03/22/2022 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: 03/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/22/2022
Section Cited

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87355(e)(2) Criminal Record Clearance
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 87355(c). CONTINUED BELOW...
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This requirement is not met as evidenced by:
Based on records reviewed, the licensee failed to ensure S1’s criminal record clearance was transferred to the facility for associated. This poses an immediate safety risk to persons in care. AN IMMEDIATE CIVIL PENALTY OF $500 IS ASSESSED.
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Type A
03/22/2022
Section Cited

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87465(a)(2) Incidental Medical and Dental Care:The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. This requirement is not met as evidence by: CONTINUE BELOW...
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Based on video reviewed, the licensee failed to meet medical needs of residents after failing to seek medical attention after R1 was observed continuously yelling in pain while being assisted by S1. R1 was transported to the hospital via their responsible party two days later. CONTINUED NEXT SECTION...
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This poses an immediate health risk to the resident in care.
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: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3


Document Has Been Signed on 03/22/2022 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: 03/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/22/2022
Section Cited

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87412(a) Personnel Records:The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information...This requirement is not met as evidence by: CONTINUED BELOW
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Based on interviews conducted, the licensee failed to ensure S1’s personnel records were retained on site. This poses a potential safety risk to persons in care.


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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: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3