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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880982
Report Date: 05/02/2024
Date Signed: 05/02/2024 11:55:47 AM

Document Has Been Signed on 05/02/2024 11:55 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:PARKVIEW RESIDENTIAL CAREFACILITY NUMBER:
331880982
ADMINISTRATOR/
DIRECTOR:		DURRANI, SULAIMANFACILITY TYPE:
735
ADDRESS:102 PARKVIEW DRIVETELEPHONE:
(714) 854-5596
CITY:CALIMESASTATE: CAZIP CODE:
92320
CAPACITY: 4CENSUS: 2DATE:
05/02/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:32 AM
MET WITH:Licensee/Administrator Sulaiman Durrani TIME VISIT/
INSPECTION COMPLETED:
12:02 PM
NARRATIVE
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On 05/02/2024 at 09:32 AM, Licensing Program Analyst (LPA) Melody Brown met with Licensee/Administrator Sulaiman Durrani to initiate a Case Management Visit. The investigation consisted of observation, interviews, and a review of pertinent documentation.

During the facility visit on 05/02/2024, Licensing Program Analyst (LPA) Melody Brown requested Client #1 (C1) facility file to review documents and LPA Brown observed that C1 does not have Physician Report (LIC602)/Medical Assessment on C1’s facility file. Licensee/Administrator Durrani reported to LPA Brown that C1 does not have form LIC602 or Medical Assessment when C1 was placed at the facility by Regional Center of Orange County (RCOC). LPA Brown explained to Licensee/Administrator Durrani that deficiency will be issued as in Adult Residential Facility (ARF), the Licensee must obtain and keep on file documentation of the client’s medical assessment prior to accepting client into care. Licensee/Administrator Durrani verbalized understanding. Licensee/Administrator Durrani was able to obtain C1 Medical Assessment during the visit on 05/02/2024 at 11:05 AM and Licensee/Administrator Durrani reported that C1 was placed at the facility on 04/07/2024.

Moreover, during the quick tour of the facility, LPA Brown observed two (2) screwdrivers and one (1) thermometer with a sharp end in the kitchen cabinet, not locked and accessible to clients in care. Deficiency will be issued. Licensee/Administrator Durrani removed the two (2) screwdrivers and one (1) thermometer in the kitchen cabinet and requested Staff #2 (S2) to lock it.

An exit interview was conducted where this report (LIC809), LIC809D and Appeal Rights were discussed and provided to Licensee/Administrator Licensee/Administrator Sulaiman Durrani.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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 05/02/2024 11:55 AM - It Cannot Be Edited


Created By: Melody Brown On 05/02/2024 at 11:11 AM
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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: PARKVIEW RESIDENTIAL CARE
FACILITY NUMBER: 331880982

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/03/2024
Section Cited
CCR
80087(g)(1)

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80087 Buildings and Grounds (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by:
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Licensee removed the two (2) screwdrivers and one (1) thermometer with sharp end in the kitchen cabinet and transferred it to a locked cabinet during the visit on 05/02/2024.
Licensee stated to train all staff on CCR 80087(g)(1) and submit proof of all staff Training Log to LPA Brown on PLan of Correction (POC) due date.
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Based on interview, observation and records review, the Licensee did not comply with the section cited above by not ensuring that the two (2) screwdrivers and one (1) thermometer with sharp end in the kitchen cabinet were locked and not accessible to clients in care which poses immediate health, safety and personal rights risk to clients in care.
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Type A
05/03/2024
Section Cited
CCR80069(b)

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80069 Client Medical Assessment (b) In ARFs , prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment. This requirement is not met as evidenced by:
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Licensee obtained C1 Medical Assessment during the visit on 05/02/2024.
Licensee stated to submit Signed Statement of Understanding on CCR 80069(b) to LPA Brown on POC due date.
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Based on interview, observation and records review, the Licensee did not comply with the section cited above by not obtaining and keep on file documentation of the Client #1 (C1) medical assessment prior to accepting C1 at the facility on 04/07/2024 which poses immediate health, safety and personal rights risks to clients 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024


LIC809 (FAS) - (06/04)
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