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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005798
Report Date: 05/18/2026
Date Signed: 05/18/2026 04:43:51 PM

Document Has Been Signed on 05/18/2026 04:43 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/
DIRECTOR:		MARIA ARRIAGAFACILITY TYPE:
740
ADDRESS:11360 WARNER AVE.TELEPHONE:
(657) 384-1001
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 170CENSUS: 144DATE:
05/18/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Peggy UllandTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation unrelated to Complaint Control No. 22-AS-20250919161621. LPA met with Administrator (AD) Peggy Ulland and explained the reason for today’s inspection.
During the course of the investigation, LPA inspected the facility, conducted interviews, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) Home Health Plan of Care, Resident #2’s (R2) Medical Records, R2’s Hospice Order, and R2’s Facility Health Care Visit Reports.

Per the facility’s wellness director, R1 had a suprapubic catheter placed while they resided in the facility and R1’s family moved them out of the facility for a higher level of care approximately three weeks later. R1 had multiple falls which were not related to the care of the suprapubic catheter, caregivers emptied R1’s catheter bag, and R1 voluntarily moved out. The facility did not have R1’s home health records, did not communicate with R1’s doctor or home health regarding R1’s catheter care needs, and had no information on what R1’s catheter care needs were and whether they were met. LPA obtained R1’s Home Health Plan of Care from the family which documents R1’s catheter care needs, but the facility was unable to show that these needs were met at the facility before R1 moved out.

Per AD and the facility’s wellness director, R2, a current resident on hospice, also has a suprapubic catheter, but the facility does not have R2’s home health or hospice records. R2’s Medical Records and R2’s Hospice Order do not identify R2’s catheter care needs. R2’s Facility Health Care Visit Reports document that R2 received two and sometimes three visits a week from home health and later hospice, catheter care was provided during many of these visits, and no concerns were noted with the care R2 was receiving for their catheter. However, the facility was unable to provide information or documentation of what R2’s catheter care needs were or whether they were met.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Sean Haddad
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PARK VIEW ESTATES
FACILITY NUMBER: 306005798
VISIT DATE: 05/18/2026
NARRATIVE
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On October 13, 2025, LPA requested the facility’s plan of operation from AD, AD was unable to locate it at the facility, and AD did not provide the plan of operation to LPA until October 29, 2025, after obtaining it from an off-site location.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Sean Haddad
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/18/2026 04:43 PM - It Cannot Be Edited


Created By: Sean Haddad On 05/18/2026 at 03:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PARK VIEW ESTATES
FACILITY NUMBER: 306005798

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/08/2026
Section Cited
CCR
87609(a)(4)

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87609 … Home Health Agencies ... (b) … (4) The licensee and home health agency agree in writing on the responsibilities … in caring for the resident’s medical condition(s). This requirement was not met as evidenced by:
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Licensee stated they will submit a protocol to LPA by POC due date for ensuring they have all required home health documentation for residents on home health.
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Based on interviews and documents, the licensee did not maintain home health agency agreements for R1 and R2 resulting in the facility not being able to confirm whether their suprapubic catheter needs were being met by home health, which poses a potential health risk to persons in care.
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Type B
06/08/2026
Section Cited
CCR87613(a)(1)

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87613 …Restricted Health Condition (a) … the licensee shall: (1) Communicate with all other persons who provide care to that resident …. This requirement was not met as evidenced by: Based on interviews and documents,
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Licensee stated they will submit a protocol to LPA by POC due date for ensuring the facility is aware of residents’ home health care needs and is following up to ensure they are being met.
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the licensee did not communicate with R1’s doctor and home health regarding R1’s suprapubic catheter care needs resulting in R1 not receiving their full required catheter care for approximately three weeks, which poses a potential health 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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Sean Haddad
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/18/2026 04:43 PM - It Cannot Be Edited


Created By: Sean Haddad On 05/18/2026 at 04:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PARK VIEW ESTATES
FACILITY NUMBER: 306005798

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/08/2026
Section Cited
CCR
87633(h)(4)

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87633 Hospice Care… (h) … the licensee shall maintain … (4) A copy of the resident’s current hospice care plan approved by the licensee, the hospice agency, and the resident… This requirement was not met as evidenced by:
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Proposed POC: Licensee stated they will submit a protocol to LPA by POC due date for ensuring they have all required hospice documentation for residents on hospice.
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Based on interviews and documents, the licensee did not maintain a copy of R2’s hospice care plan resulting in the facility not being able to confirm whether their suprapubic catheter needs were being met by hospice, which poses a potential health risk to persons in care.
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Type B
06/08/2026
Section Cited
CCR87208(a)

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87208 Plan of Operation (a) … The plan and related materials shall be on file in the facility … This requirement was not met as evidenced by:
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Licensee showed LPA a printed copy of their plan of operation and confirmed a copy would be available at the facility moving forward. POC cleared.
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Based on interviews, the licensee was unable to locate the plan of operation at the facility and had to obtain it from an off-site location, which 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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Sean Haddad
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2026


LIC809 (FAS) - (06/04)
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