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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603713
Report Date: 08/29/2024
Date Signed: 08/29/2024 11:21:24 AM


Document Has Been Signed on 08/29/2024 11:21 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:PARKVIEW MEMORY CARE AT PARADISE VILLAGEFACILITY NUMBER:
374603713
ADMINISTRATOR:AGUILAR, GEOVANNIFACILITY TYPE:
740
ADDRESS:735 ARCADIA AVENUETELEPHONE:
(619) 475-5040
CITY:NATIONAL CITYSTATE: CAZIP CODE:
91950
CAPACITY:70CENSUS: 48DATE:
08/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator Geovanni AguilarTIME COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Health Services Director Alyssa Ukaj. Administrator Geovanni Aguilar later arrived to meet with LPA.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office. According to the LIC624: on 6/17/24, Resident #1 (R1) was involved in an incident where staff restrained R1 in order to change a soiled brief after R1 went several hours refusing to be changed. [See LIC 811 Confidential Names List for a description of R1.] . No injuries reported. Facility reported incident to law enforcement, notified R1's responsible party, staff who were involved in the incident were written up and terminated, facility conducted in service training for all staff on personal rights, restraints and abuse/mandated reporting.

During today’s visit, LPA performed a facility tour / welfare check, collected records, observed R1 and interviewed staff.

One (1) deficiency was cited per California Health and Safety Code (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the Administrator.

An exit interview was conducted with Aguilar, to whom a copy of this report, the LIC809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Alyssa RamirezTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024
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 08/29/2024 11:21 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: PARKVIEW MEMORY CARE AT PARADISE VILLAGE
FACILITY NUMBER: 374603713

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2024
Section Cited
CCR
87468.1(a)(6)

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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(6)To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night.
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Licensee will conduct an in-service training on personal rights, and abuse training for staff on and provide sign in sheets to the Department by POC due date.
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This requirement is not met, evidenced by Based on records and interviews, Licensee's employee physically restrained resident (R1), preventing them from leaving the facility. This posed a potential safety risk to 1 of 48 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: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Alyssa RamirezTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024
LIC809 (FAS) - (06/04)
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