Inspection Reports for
Park View Estates Assisted Living & Memory Care

The Licensing Program Analyst conducted the visit, met with the Executive Director, and explained the purpose of the visit. An exit interview was conducted and a copy of the report was provided.

The complaint investigation was unsubstantiated for all allegations: staff neglect resulting in death of resident, failure to provide prescribed medication, falsifying medication charts, untimely response to call lights, and unqualified staff administering insulin. The investigation included interviews, record reviews, and corroboration with hospice and witnesses.

The investigation found all allegations to be unsubstantiated after interviews with staff, residents, witnesses, and review of records including medication administration records and incident reports. The resident's death was due to natural causes with hospice present, medication was administered as prescribed, call light response issues were not confirmed, and only qualified staff administered insulin.

Inspection was related to Complaint Control Number 22-AS-20250919161621; the purpose was to deliver amended findings.

During the inspection, the Licensing Program Analyst and Staff #1 reviewed and discussed previously delivered findings and amended findings. The amended report was delivered and signed by the facility representative on behalf of the Administrator. An exit interview was conducted and copies of the report were provided to the facility representative.

During the visit, the Licensing Program Analyst obtained hard copies of all residents’ progress notes, in-service training on catheter care, hospice record for one resident, staff roster, and resident roster. An exit interview was conducted with the Executive Director.

The visit was triggered by a complaint investigation under Complaint Control No 22-AS-20250929104833. The case management requires further investigation due to insufficient time and information during this visit.

During the visit, the Licensing Program Analyst requested full access to facility records but was provided limited access due to time constraints and the nature of the visit. Further investigation is required and a subsequent visit will follow.

The inspection was triggered by complaints identified by control numbers 22-AS-20250829102755 and 22-AS-20250919161621. Further investigation is required as stated in the report.

During the inspection, the Licensing Program Analyst interviewed the Administrator and staff, and reviewed resident records. The facility representative was advised that further investigation is required at this time.

Inspection was triggered by complaints under control numbers 22-AS-20250829102755 and 22-AS-20250919161621. Further investigation is required.

During the inspection, the Licensing Program Analyst interviewed the administrator and staff, and reviewed resident records. The facility representative was advised that further investigation is required at this time.

The visit was related to amending a previously issued complaint report under complaint number #22-AS-20220131170149.

The amended complaint report was reviewed and signed by the Executive Director along with this Case Management report. A copy of both reports was provided to the Executive Director for facility records.

The visit was related to amending a previously issued complaint report under complaint number #22-AS-20220131170149.

The amended complaint report was reviewed and signed by the Executive Director along with the Case Management report. No new deficiencies or findings are detailed in this report.

The complaint investigation was unsubstantiated. Allegations included resident injuries while in care, staff not properly assessing resident's change in condition, refusal to seek medical attention, shower bench disrepair, unmet laundry needs, dirty bathroom and rugs, and staff not showering resident. Investigations included interviews, record reviews, and facility tours. No violations were substantiated.

The investigation found no preponderance of evidence to substantiate any of the allegations. All complaints including resident injuries, failure to assess condition, refusal to seek medical attention, shower bench disrepair, laundry needs, bathroom and rug cleanliness, and failure to shower resident were determined to be unsubstantiated.

The complaint investigation was unsubstantiated based on the evidence collected. Allegations included failure to meet care needs, lack of access to clean water, unsecured cleaning supplies, improper medication disposal, medication dispensing errors, poor record maintenance, lack of privacy, failure to follow reporting requirements, unsecured facility records, and unavailable updated food menus. The Department found insufficient evidence to prove or refute these allegations.

The investigation found no substantiated evidence to support the allegations. Interviews with residents and staff, facility tours, and record reviews indicated that care needs were met, water and cleaning supplies were properly managed, medications were dispensed and discarded correctly, records were maintained and secured, privacy was provided, reporting requirements were followed, and updated food menus were available.

The complaint investigation addressed two allegations: 1) staff retaliated against a resident by adding unnecessary care and charging without approval, which was unsubstantiated; 2) a resident's change of condition was not reported to the physician or responsible party, which was unfounded.

The investigation found the retaliation allegation unsubstantiated due to lack of evidence, with the facility acting according to policy regarding care needs and supervision. The allegation regarding failure to report a resident's change of condition was found unfounded, as the blood-stained bandage was expected post-surgery and properly managed.

The complaint alleged that a resident received an unlawful eviction. The investigation substantiated this allegation based on interviews and document review.

The investigation found that an incomplete eviction notice was served to the resident's family, failing to include required information about alternative housing resources and the right to file a complaint. The allegation was substantiated with violations cited under California Code of Regulations Title 22.

The complaint alleged that staff represented themselves as the resident to authorize the bank to issue a check to the facility. The allegation was deemed unsubstantiated after interviews and document review.

The investigation included interviews, record reviews, and observations. The allegation was found to be unsubstantiated due to insufficient evidence to prove or refute the claim.

The facility was found to be in compliance with all reviewed areas from the Non-Compliance Conference plan agreement. No health or safety issues were observed, staff training and audits were in order, and sufficient staff were present during the visit. No deficiencies were cited.

The complaint alleged that staff did not provide authorized representatives with a 30 day eviction notice. The investigation found the allegation to be false and without reasonable basis.

The investigation found the complaint to be unfounded after reviewing documentation, interviewing the resident and witnesses, and confirming that the eviction notice was served and understood. The eviction date was extended to June 10, 2025.

The complaint included allegations that a resident sustained fractures due to staff neglect, fell multiple times due to staff neglect, was unlawfully evicted, staff did not provide the resident's authorized representative with an itemization of fee increase, and the facility internet was in disrepair. All allegations were investigated and found unsubstantiated.

The investigation included interviews with residents, staff, and former directors, and review of documents. All allegations including resident fractures due to staff neglect, multiple falls, unlawful eviction, failure to provide fee increase itemization, and internet disrepair were found to be unsubstantiated due to lack of evidence.

The complaint included allegations of resident sustaining fractures due to staff neglect, multiple falls due to staff neglect, unlawful eviction, failure to provide itemization of fee increase to resident's authorized representative, and facility internet disrepair. All allegations were investigated and found unsubstantiated.

The investigation included interviews with residents, staff, and former directors, and review of documents. All allegations were found to be unsubstantiated due to lack of evidence to corroborate neglect or violations. The resident's fractures and falls were not proven to be caused by staff neglect, the eviction notice was deemed lawful, fee increase notifications were properly provided, and the facility internet was found to be working.

The complaint was substantiated based on observations, record review, and interviews. The allegation that facility staff do not respond to the call system in a timely manner was confirmed.

The investigation found that pendant call response times were often delayed, sometimes exceeding two hours, posing an immediate health and safety risk. However, recent pendant logs showed improvement with most calls answered within twenty minutes. The allegation was substantiated and a deficiency was cited.

The complaint investigation was triggered by allegations that staff did not meet a resident's catheter needs, incontinence needs, and medical needs. The catheter care allegation was substantiated, while the others were unsubstantiated. The investigation included resident record reviews, staff and resident interviews, and witness statements.

The investigation substantiated the allegation that staff did not meet a resident's catheter needs, citing insufficient catheter care that posed a potential risk to the resident's health and safety. The allegations regarding unmet incontinence and medical needs were found to be unsubstantiated due to insufficient evidence.

The complaint alleged that staff did not ensure residents took their medication as prescribed. The investigation found no preponderance of evidence to prove the allegation, resulting in an unsubstantiated finding.

The investigation included interviews with residents and staff and review of medication administration records. The allegation was determined to be unsubstantiated as evidence showed residents received medications as prescribed and staff documented refusals appropriately.

The complaint alleged that the facility was short-staffed, staff were required to work while sick, and were asked to work seven days a week to avoid using an outside staffing agency. Interviews with residents and staff denied these allegations. The complaint was unsubstantiated.

The investigation included interviews with residents and staff, all of whom denied the staffing issues alleged. The facility was unable to provide staffing schedules from November 2021 through January 2022 due to a software change, resulting in a technical violation. The allegation of staffing shortages was found to be unsubstantiated due to lack of preponderance of evidence.

The inspection found no deficiencies in the areas inspected, including resident care, facility safety, medication storage and administration, and physical plant conditions. All required documentation was present and the facility was observed to be clean and well-maintained.

The complaint alleged inadequate supervision of a resident who spilled hot tea on themselves resulting in third degree burns and hospitalization. The allegation was unsubstantiated after investigation.

The investigation included staff interviews, resident file review, and medical record subpoena. It was determined that the resident was able to follow instructions and self-feed, and staff were nearby to assist and contacted emergency personnel immediately. The allegation of inadequate supervision was found to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged staff failed to provide supervision resulting in unmet resident needs. Interviews with staff and witnesses did not support the allegation. Staff member S1 resigned in 2023 and had no disciplinary actions. The allegation was unsubstantiated.

The investigation found no preponderance of evidence to substantiate the allegation. Staff interviews and review of records indicated no current staffing issues, and the alleged failure of supervision was unsubstantiated. A technical violation was cited for missing staffing schedules from November and December 2022, but it did not pose an immediate or potential health risk.

Licensing Program Analysts met with the Executive Director and provided an exit interview along with copies of the amended reports. No deficiencies or violations were noted in the report.

The complaint alleged that facility staff were not trained to conduct proper emergency disaster response and that the facility failed to provide adequate staffing. The investigation concluded these allegations were unsubstantiated.

The investigation found that all staff interviewed stated they were trained on emergency response and that fire and disaster drills were conducted regularly. Staffing schedules and observations indicated adequate staffing levels. The allegations were unsubstantiated due to lack of preponderance of evidence.

The visit was conducted to clear a deficiency cited during a complaint investigation on September 25, 2024.

The facility complied with the terms of the plan of correction related to maintenance and operation, specifically resolving a malfunctioning elevator issue. The deficiency is now cleared.

The complaint was substantiated. The allegation was that staff did not ensure the elevator was working properly. The investigation included observations, interviews with staff and elevator company representatives, and review of records. It was determined that the elevator was malfunctioning and repairs were delayed due to contract misunderstandings.

The investigation substantiated the allegation that the elevator was malfunctioning and not properly maintained, posing a potential health, safety, or personal rights risk to residents. The elevator was found to be non-operational due to an electrical issue beyond the scope of the contracted repair service, and poor communication delayed repairs.

The facility was found to be in compliance with all regulatory requirements during the inspection. No citations were issued. The facility was operating within its licensed capacity, maintained cleanliness, safety, and proper storage of medications and supplies, and resident and staff files were in compliance.

This visit was related to complaint control #22-AS-20240411095716. The deficiency cited was for failure to maintain a comfortable temperature in the activity room as reported by residents and observed by the Licensing Program Analysts.

The inspection found that the activity room temperature was not maintained at a comfortable level, with temperatures observed between 80 and 82 degrees Fahrenheit and residents reporting discomfort. The facility was cited for failing to maintain a comfortable temperature for residents as required by Title 22, Division 6 of the California Code of Regulations.

During the inspection, no imminent health and safety concerns were observed. The facility was clean, organized, and compliant with regulations regarding food supply, utilities, and storage of medications, sharps, and toxins. No deficiencies were cited.

The Licensing Program Analyst found no immediate or safety risks in or out of the facility during the visit. The resident involved in the incident was sent to the hospital and remains under observation.

The complaint investigation was unannounced and conducted by Licensing Program Analyst Kimberly Lyman. Allegations included insufficient incontinence supplies, failure to provide call buttons, and inadequate staffing. The investigation included facility tours, interviews with staff, residents, and witnesses, and review of documentation. The allegations were found unsubstantiated and ultimately unfounded.

The investigation found that the facility had ample incontinence supplies and call buttons were available as needed. Staffing levels were verified and found consistent with the administrator's statements, though some staff reported staffing issues while others denied them. Due to conflicting information, the allegations were deemed unsubstantiated and ultimately determined to be unfounded with no deficiencies cited.

The visit was a follow-up complaint investigation related to complaint control numbers 22-AS-20220525095746 and 22-AS-20221207111938. No substantiation status was stated.

During the inspection, the Licensing Program Analyst and Ombudsman Representative toured the Assisted Living and Memory Care Unit, conducted interviews, and made facility observations. An exit interview was conducted with the Executive Director and a copy of the report was provided.

The complaint alleging illegal eviction of a resident was investigated and determined to be unfounded based on record reviews and interviews.

The investigation found that the allegation of illegal eviction was unfounded. Documentation and interviews revealed that no eviction notice was sent to any current resident and the eviction process follows a 30-day notice as per regulation 87224.

Visit was conducted in conjunction with complaint 22-AS-20230410115728. No deficiencies or citations were issued, indicating no substantiated violations.

No hazards or safety concerns posing a threat to residents were observed. No deficiencies or citations were issued during this visit.

The complaint investigation was initiated due to allegations that the facility failed to seek medical attention for a resident, did not follow a resident's prescribed diet, and that staff were not properly trained. The first two allegations were deemed unsubstantiated, while the staff training allegation was substantiated.

The investigation found the allegations regarding failure to seek medical attention and not following the prescribed diet to be unsubstantiated due to lack of corroborating evidence. However, the allegation that facility staff were not properly trained was substantiated based on incomplete staff training records and interviews.

The visit was complaint-related, investigating two complaint control numbers. The citation was issued based on the CEO admitting to listening to a private interview, violating interview privacy requirements.

A citation was issued for failure to ensure private interviews with staff, as the Chief Executive Officer admitted to listening to a private interview with a staff member. The licensee was reminded of the importance of private interview settings and issued a citation under Title 22 Division 6, Section 87755(b).

The visit was complaint-related, addressing 14 COVID-19 positive cases reported on 8/9/2022, occurring between 7/25/2022 and 8/9/2022. The complaint was substantiated as the facility failed to report the outbreak timely.

The facility was cited for failure to report epidemic outbreaks within 24 hours as required by CCR 87211(a)(2). The Executive Director acknowledged the failure to report due to being overwhelmed, posing a potential risk to residents.

Visit was complaint-related addressing Complaint control #22-AS-20220913154817. The complaint involved 14 COVID-19 positive cases reported on 8/9/2022.

The visit addressed 14 COVID-19 positive cases reported between 7/25/2022 and 8/9/2022. The facility was cited for failure to report epidemic outbreaks within 24 hours as required by regulations.

The complaint alleged that a resident sustained multiple falls with consequential rib fractures. The investigation was unannounced and involved interviews, document reviews, and observations. The allegation was ultimately unsubstantiated due to lack of sufficient evidence.

The investigation found that Resident 1, diagnosed with Alzheimer's and Dementia, experienced multiple falls between 1/21/2022 and 1/24/2022, resulting in fractured ribs and other injuries. However, the allegation was deemed unsubstantiated due to insufficient preponderance of evidence to prove the violation occurred.

The visit was complaint-related under control number 22-AS-20211005172231. The complaint was substantiated with deficiencies found and civil penalties assessed.

Deficiencies were found including failure to associate Staff 1 (S1) properly with the facility, lack of required personnel paperwork for S1, and failure to seek medical attention or notify a physician following a resident's fall and change in condition. Civil penalties were assessed.

The inspection found the facility generally compliant with regulations, including adequate stocking of supplies and operational safety features. However, a deficiency was noted regarding hot water temperatures in resident rooms exceeding the regulatory maximum, posing an immediate health and safety risk.