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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001157
Report Date: 04/21/2026
Date Signed: 04/21/2026 10:29:29 AM

Document Has Been Signed on 04/21/2026 10:29 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:PARK TERRACEFACILITY NUMBER:
306001157
ADMINISTRATOR/
DIRECTOR:		KOEHLER, EUGENE (GENO)FACILITY TYPE:
740
ADDRESS:21952 BUENA SUERTETELEPHONE:
(949) 888-2250
CITY:RANCHO SANTA MARGARISTATE: CAZIP CODE:
92688
CAPACITY: 230CENSUS: 68DATE:
04/21/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:50 AM
MET WITH:Geno Koehler and Autumn ConquestTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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This unannounced case management visit is being conducted by Licensing Program Analyst (LPA) Ruth Martinez to follow up on an incident reported to Community Care Licensing. LPA met with Geno Koehler, Executive Director and Autumn Conquest, Assistant Executive Director and explained the purpose of today’s visit. Incident was self-reported on April 09, 2026, regarding resident (R1’s) incidents on April 07, 2026.

Staff indicated that R1 is an independent resident at the facility. On April 07, 2026, at 4:21pm R1 was observed to be having a difficult time walking in the hallway by staff. R1 complained of pain and unable to continue walking. R1 was assisted to a chair and staff immediately called paramedics. R1 was sent out to the hospital for evaluation and staff learned at a later time that R1 had injury to their left hip and under went surgery. R1 was sent to a skilled nursing for recovery once they were discharged from the hospital. R1 is currently at a skilled nursing facility until further notice. Staff upon review of the common space cameras in the hallway noted that R1 was seen walking in the hallways and turned the corner where there is a blind spot from the camera and it looks as though R1 tripped and fell to the ground. Staff was unable to determine the cause of the fall and R1 had very little information to give of the cause. R1 does not require any assisted devices for ambulating in the facility. R1 was last assessed for any changes on October 29, 2025 and does not reflect to be a fall risk or needing assisted devices for ambulating. Care plan dated October 29, 2025 does not reflect R1 to need ambulation assistance or additional services. R1's physicians report reflects that R1 is independent and does not require any assisted devices or have a motor impairment. R1's assessments

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Ruth Martinez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PARK TERRACE
FACILITY NUMBER: 306001157
VISIT DATE: 04/21/2026
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do not reflect that R1 is a fall risk. Facility will reassess R1 upon return the facility for any changes in condition and to determine if R1 requires additional care services. LPA found that facility acted appropriately and in a timely manner to address the incident. LPA did not observe any immediate and/or safety risks in or out of the facility.

Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with facility representative, and a copy of the report was furnished to the facility.

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Ruth Martinez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026
LIC809 (FAS) - (06/04)
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