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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005798
Report Date: 04/04/2023
Date Signed: 04/04/2023 04:11:14 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/23/2023 and conducted by Evaluator Patricia Velazquez
COMPLAINT CONTROL NUMBER: 22-AS-20230123104322
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: 120DATE:
04/04/2023
UNANNOUNCEDTIME BEGAN:
11:51 AM
MET WITH:Robert Jakini - Executive DirectorTIME COMPLETED:
04:25 PM
ALLEGATION(S):
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Facility failed to seek medical attention for resident
Facility is not following resident's prescribed diet
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Patricia Velazquez conducted a subsequent complaint visit to deliver the findings of the investigation into the above allegations. LPA Velazquez was allowed entry into the facility and met with Executive Director (ED) Robert Jakini and explained the purpose of the visit.

On today's visit LPA Velazquez conducted interviews with staff. LPA Velazquez also requested and obtained copies of facility, resident, and staff records. During the course of the investigation the following was revealed: LPA Velazquez conducted interviews with residents and staff. LPA Velazquez also reviewed and obtained copies of facility, resident, and staff records. The records reviewed included Resident Identification and Emergency Information, Physician's Reports, Sunshine Assessment AL/MC, Facility Resident Incident Reports, and Resident (R) #1's Residency Agreement. Nine of nine individuals interviewed provided conflicting statements and could not corroborate the above allegations. R1's records did not document any specific
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 22-AS-20230123104322
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/04/2023
NARRATIVE
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prescribed diet. Seven of seven individuals interviewed stated the facility's protocol is to call 911 for a resident when a life-threatening event or anything that poses an imminent threat to a resident’s health. These seven individuals also indicated the facility also seeks medical attention for a resident when a change of condition is observed,


Based on the observations made by LPA Patricia Velazquez, interviews which were conducted and the records that were reviewed, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the following allegations: Facility failed to seek medical attention for resident and Facility is not following resident's prescribed diet are deemed UNSUBSTANTIATED.



An exit interview was conducted with Executive Director Robert Jakini and a copy of this report along with the LIC 811 was provided at the time of this visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/23/2023 and conducted by Evaluator Patricia Velazquez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230123104322

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: 120DATE:
04/04/2023
UNANNOUNCEDTIME BEGAN:
11:51 AM
MET WITH:Robert Jakini - Executive DirectorTIME COMPLETED:
04:25 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Facility staff not properly trained
INVESTIGATION FINDINGS:
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3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Patricia Velazquez conducted a subsequent complaint visit to deliver the findings of the investigation into the above allegations. LPA Velazquez was allowed entry into the facility and met with Executive Director (ED) Robert Jakini and explained the purpose of the visit.

On today's visit LPA Velazquez conducted interviews with staff. LPA Velazquez also requested and obtained copies of facility, resident, and staff records. During the course of the investigation the following was revealed: LPA Velazquez conducted interviews with residents and staff. LPA Velazquez also reviewed and obtained copies of facility, resident, and staff records. The records reviewed included Resident Identification and Emergency Information, Physician's Reports, Sunshine Assessment AL/MC, and Resident (R) #1's Residency Agreement. Additional records reviewed including staff training records. Seven of seven individuals interviewed stated training was provided but the facility could not provide copies of complete staff training pursuant to statute and regulation. The staff training records provided to LPA Velazquez were incomplete.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20230123104322
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/04/2023
NARRATIVE
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Based on the observations of LPA Patricia Velazquez, interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Facility staff not properly trained is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 and/or the Health and Safety Code is being cited on the attached LIC 9099D.

An exit interview was conducted with Executive Director Robert Jakini and a copy of this report along with the appeal rights and LIC 9098 were provide at the time of this visit.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20230123104322
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2023
Section Cited
HSC
1569.625(a-e)
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Staff training; legislative findings; contents. The department shall adopt regulations to require staff members...who assist residents with personal activities of daily living to receive appropriate training.
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Licensee to ensure all staff are properly trained at all times pursuant to statute and regulation and submit proof of staff training to LPA by POC due date.
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This requirement is not met as evidenced by: based on interview and record review the licensee did not ensure staff received training pursuant to statute and regulation. This poses a potential risk to the health & safety of residents in care.
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Licensee to submit a written statement indicating how they intend to adhere to statute and regulation regarding staff training to LPA by POC due date.
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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: Sheila SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5