374603713-11-29-2023-08-AS-DNGN-CY32RJ-20231129163738

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603713
Report Date: 11/29/2023
Date Signed: 11/29/2023 04:38:21 PM

Document Has Been Signed on 11/29/2023 04:38 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	PARKVIEW MEMORY CARE AT PARADISE VILLAGE		FACILITY NUMBER:	374603713
ADMINISTRATOR:	AGUILAR, GEOVANNI		FACILITY TYPE:	740
ADDRESS:	735 ARCADIA AVENUE		TELEPHONE:	(619) 475-5040
CITY:	NATIONAL CITY	STATE: CA	ZIP CODE:	91950
CAPACITY:	70	CENSUS:	DATE:	11/29/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Executive Director Geovanni Aguilar		TIME COMPLETED:	04:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Geovanni Aguilar.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 11/28/2023). According to the LIC624: on 11/27/2023, Resident #1 (R1) briefly eloped (left without staff supervision) from the facility building. [See LIC 811 Confidential Names List for a description of R1.] R1 was quickly located and escorted back to the facility unharmed.

During today’s visit, LPA performed a brief facility tour and welfare check, verifying that R1 was unharmed. LPA reviewed and collected copies of pertinent care records. LPA also interview R1 and relevant staff.

According to R1’s latest LIC602 Physician’s Report (dated 11/01/2023): R1 was diagnosed with Dementia, and their doctor determined that they were not able to safely leave the facility unassisted.

Interviews and care records showed: R1 had moved into the facility about a week before the incident. On 11/27/2023 around 10:45 AM, a staff person saw R1 in the facility’s parking lot and redirected R1 back inside, unharmed. Ten to twenty minutes prior, R1 was seen inside the facility by multiple staff. Camera footage showed R1 exited from a corner of the facility where there were no doors. Staff observed within this immediate area was a vacant resident room, where there was a broken window stop (designed to prevent the window from being fully opened) and a dislodged window screen. The parking lot where R1 was located was immediately adjacent to this window. Although R1 could not recall details of the elopement incident, circumstantial evidence showed that R1 forcibly exited the facility via this window.

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PARKVIEW MEMORY CARE AT PARADISE VILLAGE	FACILITY NUMBER: 374603713
	VISIT DATE: 11/29/2023

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[CONTINUED FROM LIC 809]

LPA observed: Licensee had since repaired the above referenced window stop and window screen. Staff alert and delayed-egress devices on exit doors (where residents diagnosed with Dementia reside) were operational. Licensee possessed a written Absentee Notification Plan as part of R1’s record of care. Licensee had since updated R1’s Plan of Care to increase routine observation for them. Training records shows: On 11/28/2023, Licensee educated direct care staff on how to respond to residents’ “Wandering Behavior” and “Exit Seeking Behavior.”

During today’s visit, LPA reviewed data on R1’s biography and likes and dislikes, which Licensee had obtained as part of its pre-admission appraisal. LPA provided Licensee with Technical Assistance (TA) on how to make this information more accessible and actionable to the direct care staff.

No deficiencies were observed or cited during today's visit.

An exit interview was conducted with Aguilar, to whom a copy of this report, the LIC9102-TA, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

LIC809 (FAS) - (06/04)

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