306005798-10-14-2025-22-AS-APAO-DMM56V-20251019194119

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005798
Report Date: 10/14/2025
Date Signed: 10/14/2025 03:03:27 PM

Unsubstantiated

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
04/23/2024 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240423101324

FACILITY NAME:	PARK VIEW ESTATES		FACILITY NUMBER:	306005798
ADMINISTRATOR:	ROBERT A. JAKINI		FACILITY TYPE:	740
ADDRESS:	11360 WARNER AVE.		TELEPHONE:	(949) 333-3486
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	170	CENSUS: 148	DATE:	10/14/2025
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Peggy Ulland		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff do not ensure the care needs of residents are being met
Staff doe not ensure residents have access to clean water for consumption
Staff does not ensure cleaning supplies are safely secured from residents
Staff does not ensure discontinued medications are properly discarded
Staff does not dispense medications as prescribed
Staff do not ensure residents records are properly maintained
Staff do not ensure residents are provided personal privacy
Staff does not ensure reporting requirements are followed
Licensee does not ensure facility records are safely secured
Staff do not ensure updated food menus are made available to residents

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude investigation into the above identified complaint allegations. LPA arrived at the facility and was greeted and granted entry. LPA spoke with Peggy Ulland, Executive Director, and explained the purpose of the visit.

Findings are based upon this investigation which included tour of the facility, facility file review, resident file review, interviews conducted, and pertinent documents collected.

It is alleged facility staff do not ensure the care needs of the resident’s are being met. Records review revealed that all logs reflect residents are on a schedule for services at the facility and logs reflect as services performed. Interview with staff stated that residents get the care they need and there is no issue

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025

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 4

Control Number 22-AS-20240423101324

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: 10/14/2025

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

with doing so. Interview with 10 of 10 residents stated that they get the care they need, get the assistance they ask for, and they don’t have a problem with getting care.

It is alleged that staff does not ensure residents have access to clean water for consumption. LPA Martinez conducted a tour of the facility on April 30, 2024, and on October 8, 2025, and did not observe the water containers used for water are clean and clear of any mold, or dirt. LPA did not observe any issues with the water that is used for consumption or available to residents. Interview with executive chef stated We have a water container in the memory care unit where we clean it out twice a day. Generally, it has slices of fruit in the water for flavor. That is available for residents all the time and the water containers are changed out often for fresh water. Interview with 10 of 10 residents stated that they have not noticed the water to be dirty and they can ask for a cup of water at any time and get it.

It is alleged that staff does not ensure cleaning supplies are safely secured from residents. LPA Martinez conducted a tour of the physical plant of the facility on the following dates: April 30, 2024, and October 8, 2025, and did not observe any toxins, cleaning supplies or chemicals in any common spaces or the kitchen of the facility. LPA inspected that facility has a centralized storage unit for toxins located in the back hallway of the facility which residents do not have access to, the toxins are kept in the storage unit as well as in the maintenance director’s office. Entry door to the hallway is by the entry of the dining room and only access by a key card. Interview with staff stated that when the housekeepers or any other staff need cleaning supplies or toxins that they retrieve from the storage unit and then return to the same unit. Each housekeeper has a cart that they load toxins and unload at their end of shift in the storage unit. Interview with 10 of 10 residents stated that they don’t have access to the kitchen and they have not seen any toxic chemicals just laying around in the facility.

It is alleged that staff does not ensure discontinued medication are properly discarded. LPA conducted a facility visit and toured the medication room for the facility on April 30, 2024, and October 8, 2025, and observed that in the medication room there is a container that is used to discard medication. The container is in a room that requires a key card to enter. Interview with lead med tech stated that there is a container to discard discontinued medication in the medication room. Container is a one way entry and you cannot retrieve
Continued on LIC9099-C

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 22-AS-20240423101324

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: 10/14/2025

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 medication once it is dispensed in the container. Once medication is disposed there isn’t a way to retrieve the medication or remove it from the container. Once the container is full there is a shipping label adhered to the box with a phone number that is called for pick up by a vendor.

It is alleged that staff does not dispense medication as prescribed. Record obtained for MAR (medication administrator records) for March and April of 2024 revealed that all medication was given accordingly and there are no missed dosages. Interview with staff stated that medication is given then logged out in the computer system to indicate that it was given. Interview with 10 of 10 residents stated that they get their meds and they haven’t not had issue with not getting the medication. Staff comes to them and gives them medication at the time that it is due.

It is alleged that staff do not ensure residents records are properly maintained. A review of 13 resident records revealed that all resident files contained required documentation including updated physician reports and care plans and are complete. Interview with staff stated that all records are kept electronically and they also have a physical file on hand in the event it is needed for review. At the time of visit records requested were made available to LPA.

It is alleged that staff do not ensure residents are provided with personal privacy. LPA toured the facility and observed that resident bedrooms are apartment style units with a main door for entry. Interview with 10 of 10 residents stated that they feel like they have privacy at the facility and in their bedroom. They stated that they have privacy at the facility in their bedroom, common spaces and with their relationships with other residents.
It is alleged that staff does not ensure reporting requirements are followed. Record review revealed that CCLD has on records as receiving LIC624 unusual report about the staff and residents at the facility. CCLD has received reports such as falls, staff, and elopements to name a few incident types received. Interview with staff stated that they report out any incident no matter if it is with residents or staff. Staff stated there was an incident with staff last month (March of 2024) that as reported to CCLD and LPA Rosie came out and did a visit for it. stated stated they knew that they need to report incidents to the department.

It is alleged that licensee does not ensure facility records are safely secured. LPA Martinez conducted a facility visit April 30, 2024, and requested to view records. LPA toured the facility and observed that records

Continued on LIC9099-C

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 22-AS-20240423101324

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: 10/14/2025

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

for staff are kept locked in the Executive Director’s office and resident records are located locked in the first floor medication room and/or on each floor where resident resides. Facility also has electronic records that are kept in their system with a passcode locked. Interview with staff stated that records can be accessed by staff with a key if they have access to them. Employee records are only accessed by the business office director, resident records only have access by med techs, but financial documents are separated, and they don’t have access to that section of records, and caregivers have access to the PCC system that is used for electronic files.

It is alleged that staff do not ensure update food menus are made available to residents. LPA conducted a tour of the facility on various dates and observed that there is a monitor mounted on the wall of the entry of the dining room displaying menus digitally, menus for specials physically displayed outside the dining, printed menus on tables, and menus in the reception area of the lobby. Interview with kitchen staff sated there is an always available/regular menu on the tables in the dining room, 24 hours specials that are on the dining room TV that run 7 days of specials lunch and dinner and snack menu that are given at 10:00am/2pm/7pm for 7 days a week, staff print out menus to cover all residents each Monday morning.

Based on the information mentioned above, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegations is deemed Unsubstantiated.

An exit interview was conducted with the Executive Director and a copy of this LIC9099 report was left at facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4