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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603713
Report Date: 02/04/2026
Date Signed: 02/04/2026 05:47:51 PM

Document Has Been Signed on 02/04/2026 05:47 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:PARKVIEW MEMORY CARE AT PARADISE VILLAGEFACILITY NUMBER:
374603713
ADMINISTRATOR/
DIRECTOR:		JIMENEZ, KATRINAFACILITY TYPE:
740
ADDRESS:735 ARCADIA AVENUETELEPHONE:
(619) 399-5988
CITY:NATIONAL CITYSTATE: CAZIP CODE:
91950
CAPACITY: 70CENSUS: 49DATE:
02/04/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:50 AM
MET WITH:Executive Director Katrina JimenezTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
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
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 Katrina Jimenez and Health Services Director Leah Adolfo.

Today's visit was in response to an LIC624 Incident Report, which Licensee self-submitted to the CCLD San Diego Regional Office (received on 02/02/2026). Per this LIC624, Resident #1 (R1) had an unwitnessed fall on 01/31/2026, and facility staff subsequently sent R1 to local hospital emergency room (ER) on 02/01/2026. [See LIC 811 Confidential Names List for a description of person identifiers used in this report].

During today’s visit, LPA performed a brief facility tour / welfare check on R1, collected and reviewed relevant care and medical records, and interviewed R1 and multiple pertinent facility staff. Due to their Alzheimer’s Disease diagnosis, R1 was not a reliable historian. However, records and staff interviews taken together showed:

On 01/31/2026, R1 fell three (3) times inside their bedroom within one day, at around 11:50 AM, 1:00 PM, and 6:21 PM, respectively. The 11:50 AM fall did not involve any suspected injury. The 1:00 PM fall involved a bump on head, for which 911 paramedics responded, but for which R1 and their responsible person also declined transport to the hospital. The 6:21 PM fall involved pronounced pain to R1’s right shoulder area, which was immediately apparent to responding facility staff. Rather than call 911 again for R1, staff assisted R1 to bed and alerted R1’s hospice agency. Facility staff provided R1 as-needed morphine for pain, and the hospice agency dispatched a nurse a few hours later to perform a follow up visit on R1.

[CONTINUED ON LIC 809-C]

NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: PARKVIEW MEMORY CARE AT PARADISE VILLAGE
FACILITY NUMBER: 374603713
VISIT DATE: 02/04/2026
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
[CONTINUED FROM LIC 809]

However, by the morning of 02/01/2026, R1 remained in pain, and their right shoulder area was now significantly discolored, so staff arranged for R1 to be transported to the hospital ER; R1 departed the facility around 11:03 AM. Per hospital ER records, R1 was diagnosed with a new “closed displaced comminuted fracture of shaft of right humerus.” (A comminuted fracture is a type of injury where the bone breaks in multiple places. A displaced fracture means the fragments have moved out of normal anatomical alignment, creating a gap or misalignment.)

CCR 87465(g) requires Licensees to “immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health.” Regarding residents receiving hospice care, CCR 87469(c)(3) specifies, “For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1).” CCLD concluded that the injury to R1’s right shoulder/arm was serious and required staff to call 9-1-1. This injury also was not related to the expected course of R1’s underlying terminal illness/diagnosis.

To date: The available evidence did not clearly show that Licensee’s delay in activating 911 worsened R1's injury. The available evidence also showed that Licensee had performed Care Plan updates/reappraisals on R1 in the past, as required.

One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the Licensee.

An exit interview was conducted with Executive Director Katrina Jimenez and Health Services Director Leah Adolfo, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/04/2026 05:47 PM - It Cannot Be Edited


Created By: Dang Nguyen On 02/04/2026 at 05:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/04/2026
Section Cited
CCR
87469(c)(3)

1
2
3
4
5
6
7
87469 Advanced Directives and Requests Regarding Resuscitative Measures: “(c)(3) Specifically for a terminally ill resident that is receiving hospice services…For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1).” This requirement was not met, as evidenced by:
1
2
3
4
5
6
7
On 02/02/2026, prior to CCLD’s case management visit, Licensee had already conducted an in-service retraining with its staff, educating them to call 911 when the resident’s medical emergency is not directly related to the expected course of the resident’s terminal illness. Licensee reminded its staff that while a resident and their responsible person may refuse transport to the hospital, such refusals should be made directly to first responders, after said personnel have already met with and inspected the resident. The Plan of Correction is Satisfied.
8
9
10
11
12
13
14
Based on records and interviews, for 1 of 49 residents (R1), who was receiving hospice care services and experiencing an emergency not directly related to the expected course of their terminal illness, Licensee’s staff did not immediately telephone emergency response (9-1-1). This posed a potential health 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2026


LIC809 (FAS) - (06/04)
Page: 4 of 4