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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405801595
Report Date: 03/29/2022
Date Signed: 03/29/2022 04:12:52 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/21/2022 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20220321160327
FACILITY NAME:PARKVIEW VILLAGE IIFACILITY NUMBER:
405801595
ADMINISTRATOR:I.PATACSIL & C. PATACSILFACILITY TYPE:
740
ADDRESS:1577 BADEN AVE.TELEPHONE:
(805) 474-9030
CITY:GROVER BEACHSTATE: CAZIP CODE:
93433
CAPACITY:6CENSUS: 4DATE:
03/29/2022
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Abraham Garces, Back up to AdministratorTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Staff are not following masking requirements
Medication was left unlocked and accessible to residents
Pesticide was left accessible to resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rachael De Leon conducted a 10-day complaint visit to the facility above. LPA met with Back up Administrator Abraham Garces and explained the purpose of the visit.

LPA took a physical plant tour of the inside of the facility at 3:00 PM. LPA opened all cabinets and cupboards throughout the facility from 3:00 PM to 3:21PM. LPA observed the medication area cabinets locked and inaccessible to residents in care. LPA requested the following documentation on 03/29/2022 at 3:23 PM and reviewed for relevant information: Resident Roster, Staff Roster and Staff Schedule for 03/17/2022. LPA interviewed Credible Witness on 03/25/2022 at 8:46 AM. LPA interviewed staff on 03/29/2022 at 3:24 PM.
Continued 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
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 29-AS-20220321160327
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PARKVIEW VILLAGE II
FACILITY NUMBER: 405801595
VISIT DATE: 03/29/2022
NARRATIVE
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On the allegation: Staff are not following masking requirements. LPA interviewed credible witness (W1) which revealed staff 1 (S1) answered the door without a mask on 03/17/2022 around 12:30 PM and did not put one on until prompted by another staff 2 (S2) to do so. S1 continued to wear the mask below the nose when W1 was present on 03/17/2022. S1's interview revealed that S1 was not wearing a mask on that date and will make sure to wear one at all times in the facility. Based on the observation of W1 on 03/17/2022 this allegation is deemed Substantiated at this time.

On the allegation: Medication was left unlocked and accessible to residents. LPA interviewed W1 which revealed that on 03/17/2022 around 12:30 PM W1 observed a medication capsule in the top right drawer of a desk by the kitchen labelled use for loose stool. W1 observed the drawer to not have a lock making the medication accessible to residents in care. S2's interview stated the medication bottle was empty. Based on the observation the allegation is deemed Substantiated at this time.

On the allegation: Pesticide was left accessible to resident. LPA’s interview with W1 revealed on 03/17/2022 around 12:30 PM W1 observed a pesticide in a plastic syringe labelled cockroach killer in the top right drawer of a desk by the kitchen. W1 observed that the drawer did not have a lock which made it accessible to the residents in care. S2's interview acknowledged the item was left in the unlocked drawer and it was locked up. Based on W1 observation the allegation is deemed Substantiated at this time.

Exit interview conducted, deficiencies cited, copy of report and appeal rights emailed to the Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20220321160327
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PARKVIEW VILLAGE II
FACILITY NUMBER: 405801595
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/30/2022
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in all Facilities: ...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Administrator agreed to immediately implement mask wearing in the facility. Conduct training on Mask/Infectious Disease Prevention with all staff. Provide training records with all staff signatures to CCL.
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Based on interviews the licensee did not ensure all staff were wearing face coverings in the facility which poses an immediate health, safety and personal rights risk to residents in care.
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Type B
04/05/2022
Section Cited
ILS
87465(h)(2)
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(h)...(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible...This requirement was not met as evidenced by:
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Administrator agreed to go through all cupboards/drawers/cabinets in the facility and make sure all medications are locked up and inaccessible to residents in care, provide medication training to all
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Based on W1 observation the licensee did not ensure all medications were locked which poses an potential health and safety risk to residents in care.
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staff and provide staff training with signatures to CCL.
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: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20220321160327
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PARKVIEW VILLAGE II
FACILITY NUMBER: 405801595
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/05/2022
Section Cited
CCR
87705(f)(2)
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(f)...(2)Over-the-counter medication,...,and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement was not met as evidenced by:
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Administrator agreed to go through all cupboards/drawers/cabinets in the facility and make sure all toxic products are locked up and inaccessible to residents in care, provide training on reg 87705 to
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Based on W1 observation the Licensee did not ensure all toxic products were locked up which poses an ptential health and safety risk to residents in care.
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all staff and provide staff training with signatures to CCL.
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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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4