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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005798
Report Date: 09/21/2022
Date Signed: 09/21/2022 11:42:54 AM


Document Has Been Signed on 09/21/2022 11:42 AM - 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: 98DATE:
09/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:46 AM
MET WITH:Sheila Fike, Executive DirectorTIME COMPLETED:
11:45 AM
NARRATIVE
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On today’s date, Licensing Program Analyst (LPA) Rosie Quiroz made a subsequent visit following an unannounced visit addressing Complaint control #22-AS-20220913154817. LPA Quiroz met with Sheila Fike, Executive Director (ED) and discussed the purpose for today’s visit.

During today's visit, LPA Quiroz addressed 14 COVID-19 positive cases reported on 8/9/2022 which occurred between 7/25/2022 through 8/9/2022. This was verified with (ED) Sheila Fike.

The facility is being cited per Title 22, Division 6 of the California Code of Regulations. (SEE LIC 809-D)

An exit interview was conducted with (ED) Sheila Fike, and a copy of this report, along with LIC 809-D, Appeal Rights were provided at exit.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
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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Document Has Been Signed on 09/21/2022 11:42 AM - 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: 09/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2022
Section Cited

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87211(a)(2)Reporting Requirements:(a)Each licensee shall furnish to the licensing agency such reports...(2)Occurrences, such as epidemic outbreaks...shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. CONTINUED BELOW
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This requirement was not met as evidenced by: (ED) Fike indicated "Too much going on and it escaped me to report to CCLD." This poses a potential risk for residents 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: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
LIC809 (FAS) - (06/04)
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