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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880982
Report Date: 12/17/2024
Date Signed: 12/17/2024 12:07:38 PM

Document Has Been Signed on 12/17/2024 12:07 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
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: 1DATE:
12/17/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Michael Jason Camarillo TIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On 12/17/2024 at 11:15 AM, Licensing Program Analyst (LPA) Melody Brown met with staff Michael Jason Camarillo to initiate a Case Management Visit. Licensee/Administrator Sulaiman Durrani was contacted and informed of the visit and Licensee/Administrator Durrani designated staff Michael Jason Camarillo to sign the report as Licensee/Administrator Durrani's unavailable for the visit. The investigation consisted of interviews and review of pertinent documentation.

During the facility visit on 12/09/2024, Licensing Program Analyst (LPA) Melody Brown requested Client #1 (C1) Unusual Incident/Injury Report (LIC624) on 05/17/2024 and per document review and interview with Staff #2 (S2), LPA Brown noted that the facility did not report the manual restraint conducted my S2 to C1 to C1's authorized representative and to Community Care Licensing Department (CCLD). LPA Brown explained to staff Camarillo that deficiency will be issued.

An exit interview was conducted where this report (LIC809), LIC809D and Appeal Rights were discussed and provided to staff Michael Jason Camarillo.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/17/2024 12:07 PM - It Cannot Be Edited


Created By: Melody Brown On 12/17/2024 at 11:33 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: 12/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/26/2024
Section Cited
CCR
85161(a)

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85161 Emergency Intervention Documentation and Reporting Requirements (a) Each use of manual restraint or seclusion shall be reported to the client's authorized representative, if any, by telephone...This requirement is not met as evidenced by:
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Licensee stated to train all staff on CCR 85161(a) and submit proof of all staff training log to LPA Brown by the Plan of Correction (POC) due date.
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Based on interview and record review, the Licensee did not comply with the section cited above by not ensuring that the manual restraint conducted by Staff #2 (S2) to C1 was reported to C1 authorized representative which poses a potential health, safety and personal rights risk to client in care.
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Type B
12/26/2024
Section Cited
CCR85161(b)

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85161 Emergency Intervention Documentation and Reporting Requirements (b) Each use of manual restraint or seclusion shall be reported to the Department in writing no later than the next business day...This requirement is not met as evidenced by:
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Licensee stated to train all staff on CCR 85161(b) and submit proof of all staff training log by the POC due date.
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Based on interview and record review, the Licensee did not comply with the section cited above by not ensuring that the manual restraint conducted by Staff #2 (S2) to S1 was reported to CCLD which poses a potential health, safety and personal rights risk to client 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: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


LIC809 (FAS) - (06/04)
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