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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005798
Report Date: 07/27/2023
Date Signed: 07/27/2023 02:35:07 PM

Unfounded


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
06/12/2023 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20230612152958
FACILITY NAME:PARK VIEW ESTATESFACILITY NUMBER:
306005798
ADMINISTRATOR:ROBERT A. JAKINIFACILITY TYPE:
740
ADDRESS:11360 WARNER AVE.TELEPHONE:
(949) 333-3486
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:150CENSUS: 109DATE:
07/27/2023
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Robert JakiniTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
Facility does not have sufficient incontinence supplies to meet residents’ needs
Facility did not provide resident with call button
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility by Executive Director Robert Jakini and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, observed incontinence supplies, interviewed staff, residents and witnesses as well as reviewed and obtained pertinent documentation such as staff schedule. Regarding the allegations that facility does not have sufficient incontinence supplies to meet residents’ needs and facility did not provide resident with call button, the investigation revealed the following: LPA observed facility incontinence supplies on two different occasions. On both occasions observed, facility had ample and varied incontinence supplies and LPA observed no concerns with supplies. All facility rooms have a pull cord in the restroom and sleeping area. Personal pendants are provided to residents on an as needed basis or by request of resident/ family. Per Administrator, at time of complaint there were no new admits requesting or needing a personal pendant. Administrator denies any new admits at time of investigation having a fall or needing a pendant. CONTINUED ON LIC 9099C DATED 07/27/2023.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
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 4
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
06/12/2023 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20230612152958

FACILITY NAME:PARK VIEW ESTATESFACILITY NUMBER:
306005798
ADMINISTRATOR:ROBERT A. JAKINIFACILITY TYPE:
740
ADDRESS:11360 WARNER AVE.TELEPHONE:
(949) 333-3486
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:150CENSUS: 109DATE:
07/27/2023
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Robert JakiniTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to provide adequate staffing to meet residents’ needs
INVESTIGATION FINDINGS:
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2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility by Executive Director Robert Jakini and explained the reason for the visit.

During the course of the investigation, LPA toured the facility, interviewed staff, residents and witnesses as well as reviewed and obtained pertinent documentation such as staff schedule. Regarding the allegation that facility failed to provide adequate staffing to meet residents’ needs, the investigation revealed the following: Administrator indicates staffing levels include 3 caregiver/ 1 med tech for 1st and 2nd shift and 2 caregiver/ 1 med tech for NOC shift for each side, assisted living and memory care. Staffing schedule provided verifies this staffing level. Administrator states using Brightstar Care staffing agency to fill holes as needed. Five out of ten staff indicate consistent staffing issues at the facility. Five out of five witnesses deny staffing issues and state no neglect or issues with staffing. Ten out of ten staff deny any knowledge of a undiscovered deceased resident in the facility. CONTINUED ON LIC 9099C DATED 07/27/2023.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
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 4
Control Number 22-AS-20230612152958
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: 07/27/2023
NARRATIVE
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Due to conflicting information, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 22-AS-20230612152958
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: 07/27/2023
NARRATIVE
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Therefore the allegations are determined to be UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis.
No deficiencies cited.

An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4