306005798-12-30-2024-22-AS-AORZ-DEBN7U-20250228091315

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005798
Report Date: 12/30/2024
Date Signed: 12/30/2024 09:37:50 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
05/25/2022 and conducted by Evaluator RoseMarie Ruppert

COMPLAINT CONTROL NUMBER: 22-AS-20220525095746

FACILITY NAME:	PARK VIEW ESTATES		FACILITY NUMBER:	306005798
ADMINISTRATOR:	HEATHER MYERS		FACILITY TYPE:	740
ADDRESS:	11360 WARNER AVE.		TELEPHONE:	(949) 333-3486
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	150	CENSUS: 123	DATE:	12/30/2024
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Peggy Ulland, Executive Director		TIME COMPLETED:	09:35 AM

ALLEGATION(S):

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Facility staff did not provide adequate supervision to resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Rose Ruppert and Fred Arias made an unannounced complaint visit to deliver findings for the above allegation from May 25, 2022. LPA was greeted and granted entry into the facility by the concierge and met with Peggy Ulland, Executive Director and stated the purpose of the visit.

During the investigation LPA Rosie Quiroz conducted a health and safety visit and interviewed Resident 1 (R1). The Department received a report that stated R1 spilled hot tea upon self and was sent to the hospital. LPAs Quiroz and Ruppert interviewed staff regarding the events from 2022 to determine if there was adequate supervision of the resident LPA Ruppert requested the resident’s file and the May 2022 staffing schedule. LPA Ruppert also subpoenaed resident records from Orange County Global Medical Center for the dates of May 20-22, 2022. Record review stated resident received third degree burns and was referred to the Burn Unit.

(Continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20220525095746

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/30/2024

NARRATIVE

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(Continued from LIC 9099)

LPA conducted three of three staff interviews, reviewed resident file and the Physician’s Report dated January 21, 2022. it was determined, by the medical assessment, that the resident was able to follow instructions and self-feed. At the time of the incident, three of three staff interviews stated staff were nearby to assist resident and contacted emergency personnel immediately.

Although the above allegations may have happened there is not a preponderance of evidence to prove the alleged violation occurred; therefore, the allegation that facility staff did not provide adequate supervision to resident in care is Unsubstantiated.

An exit interview was conducted with Peggy Ulland, Executive Director (ED) and a copy of this report was provided to the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024

LIC9099 (FAS) - (06/04)

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