<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005798
Report Date: 09/25/2024
Date Signed: 09/25/2024 12:06:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/23/2024 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240923083308
FACILITY NAME:PARK VIEW ESTATESFACILITY NUMBER:
306005798
ADMINISTRATOR:MARIA ARRIAGAFACILITY TYPE:
740
ADDRESS:11360 WARNER AVE.TELEPHONE:
(949) 333-3486
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:150CENSUS: 115DATE:
09/25/2024
UNANNOUNCEDTIME BEGAN:
07:32 AM
MET WITH:Peggy Ulland- Executive DirectorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure the elevator is working properly.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the 10-day complaint investigation into the above allegation. LPA was greeted and granted entry by Receptionist Paige Pheng and explained the purpose of the visit to Executive Director (ED) Peggy Ulland. During today's visit, LPA conducted a self-guided tour of the facility and observed a 'Do Not Enter Elevator Not Working' sign on one out of the two elevators on the property. Elevator was also tested during today's visit. LPA interviewed four staff and the representatives at the elevator company, and pertinent records were obtained which includes: Resident/Staff Roster, email receipt, and the elevator inspection report.

The investigation revealed the following: It is alleged that staff did not ensure that the elevator is not working properly. LPA, ED, and Maintenance Director (MD) Matt Yem observed that the power to the Program Logic Control (PLC) Board which runs the elevator was not turning on approximately 11:35am. Per review of MD's video recording, the PLC board was working at 11:09am today. LPA, ED, and MD made a phone call to the elevator company's dispatch center, OTIS.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 22-AS-20240923083308
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 VIEW ESTATES
FACILITY NUMBER: 306005798
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2024
Section Cited
CCR
87303(a)
1
2
3
4
5
6
7
87303 Maintenance and Operation(a) The facility shall be... safe,... and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator stated that the elevator will be repaired and will notify LPA via email on or before the POC due date when the issue has been resolved.
8
9
10
11
12
13
14
Based on LPA's observations, interviews, and record review, the elevator is currently malfunctioning which poses a potential Health, Safety, or Personal Rights risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20240923083308
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 VIEW ESTATES
FACILITY NUMBER: 306005798
VISIT DATE: 09/25/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The dispatch operator reported that per her records, the initial repair was conducted on September 19, 2024 approximately 7:57pm and was completed successfully which was verified on the inspection report. A second service request was submitted to OTIS on September 20th, and the technician came to the facility the same day at 1:15pm per dispatch operator. However, the elevator issue was not resolved as the service technician indicated per MD Yem that the electrical issue was beyond his scope of work. Interviews conducted with four out of the four staff revealed that the elevator was successfully repaired on the 19th. Facility made attempts to reach out to the licensee's representative, seeking assistance on September 24th and 25th via email. Phone calls were made with two representatives from OTIS and Sunshine Retirement. Both representatives acknowledged that the facility is responsible for completing the repairs as it was not part of the contract, and facility was advised by OTIS to call an outside electrician. It was determined during the investigation that Elevator 2 is not working at this time. Facility was observed arranging a service with the electrician during the visit. It appears based on the investigation, that there was poor communication and/or misunderstanding of the contract which delayed the repair of the elevator since the 20th.

Therefore, based on LPA's observations, interviews which were conducted, and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Staff did not ensure the elevator is working properly is deemed SUBSTANTIATED as per Title 22, Division 6, Chapter 8 of the California Code of Regulations. A deficiency is being cited on the attached LIC 9099D.

An exit interview was conducted with Executive Director Peggy Ulland, and a copy of this report, LIC9099D, and the appeal rights were provided at exit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3