Inspection Reports for Park Terrace
21952 Buena Suerte, Rancho Santa Margarita, CA 92688, United States, CA, 92688
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, including the most recent annual inspection on June 16, 2025, which was free of any issues. There was one substantiated complaint investigation in May 2025 involving a medication error where a resident received another resident’s medication and a missing signed care plan, both considered minor but important documentation and medication management concerns. Several other complaint investigations, including allegations of physical abuse and medication refusal, were unsubstantiated due to insufficient evidence. Earlier annual inspections showed only minor maintenance issues that were addressed without formal deficiencies. The facility’s record shows improvement over time, with recent reports demonstrating compliance and no serious enforcement actions or fines listed in the available reports.
Deficiencies per Year
4
3
2
1
0
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 179
Capacity: 230
Deficiencies: 0
Jul 29, 2025
Visit Reason
An unannounced visit was conducted to investigate complaints alleging that facility staff refused to give medication to a resident and were not following doctors' orders.
Findings
The investigation found that medication changes were documented and administered as prescribed, with no discrepancies in medication administration records. The allegation that staff refused medication or did not follow doctors' orders was deemed unsubstantiated due to lack of sufficient evidence.
Complaint Details
The complaint involved allegations that facility staff refused to give medication (specifically Seroquel and Ativan) to a resident and did not follow doctors' orders. The investigation included interviews, record reviews, and a facility tour. It was found that the resident never had a physician's order for Ativan, and medication changes were properly documented and administered. The allegation was unsubstantiated.
Report Facts
Facility capacity: 230
Resident census: 179
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the complaint investigation |
| Geno Koehler | Executive Director | Met with investigator during the visit |
| Armando J Lucero | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 172
Capacity: 230
Deficiencies: 0
Jun 16, 2025
Visit Reason
The visit was an unannounced annual required inspection conducted by Licensing Program Analyst Ruth Martinez to evaluate compliance with licensing requirements for the Park Terrace facility.
Findings
The inspection found no deficiencies in the areas inspected, including resident care, physical plant, medication storage, safety systems, and documentation. All safety equipment was up to date and functioning properly, and resident and staff files contained required documentation.
Report Facts
Hospice residents: 10
Resident bedrooms inspected: 10
Resident files reviewed: 10
Staff files reviewed: 5
Water temperature range: 115.9 to 117.5
Pool fence height: 70
Fire sprinkler last tested: Jan 10, 2025
Smoke/carbon monoxide detectors last tested: Feb 7, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the unannounced annual inspection visit |
| Autumn Conquest | Assistant Executive Director | Met with Licensing Program Analyst during inspection |
| Ito Chong | Assisted Living Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 169
Capacity: 230
Deficiencies: 2
May 19, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2025-04-10 alleging medication errors, lack of resident involvement in care planning, and improper assessment with change in condition.
Findings
The investigation substantiated that staff gave a resident another resident's medication on 2025-04-05 without adverse reaction and that the resident was not involved in the care plan as required. Another allegation regarding improper assessment with change in condition was found unsubstantiated due to insufficient evidence.
Complaint Details
The complaint was substantiated for allegations that staff gave a resident another resident's medication and that the resident was not involved in the care plan. The allegation that staff did not do a proper assessment with change in condition was unsubstantiated due to lack of sufficient evidence.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| The licensee did not ensure Resident 1 received assistance with self-administered medications due to a medication error, posing a potential health risk. | Type B |
| The licensee does not have a signed care plan by the resident as required within two weeks of admission. | Type B |
Report Facts
Capacity: 230
Census: 169
Deficiencies cited: 2
Plan of Correction Due Date: Jun 2, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Armando J Lucero | Licensing Program Manager | Reviewed the complaint investigation report |
| Autumn Conquest | Assistant Executive Director | Met with Licensing Program Analyst during the inspection |
Inspection Report
Complaint Investigation
Census: 184
Capacity: 230
Deficiencies: 0
Apr 30, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the facility physically abused a resident.
Findings
The investigation included a review of the resident's file, a physical plant tour, and interviews with staff and residents. The allegation was deemed unsubstantiated due to insufficient evidence to prove or refute the claim.
Complaint Details
The complaint alleged that Resident 1 had unexplained bruising and had experienced a fall. Staff and resident interviews indicated the resident fell but did not report it at the time. The investigation was unable to ascertain if the alleged physical abuse occurred, resulting in an unsubstantiated finding.
Report Facts
Capacity: 230
Census: 184
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the complaint investigation |
| Hanna Gough | Licensing Program Analyst | Conducted the complaint investigation |
| Geno Koehler | Executive Director | Met with investigators and was informed of the findings |
| Armando J Lucero | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 176
Capacity: 230
Deficiencies: 0
Feb 3, 2025
Visit Reason
This unannounced case management visit was conducted to follow up on an incident reported to Community Care Licensing regarding a resident's fall on January 22, 2025.
Findings
The facility acted appropriately and in a timely manner to address the incident and injuries. No immediate or safety risks were observed, and no deficiencies were noted during the visit.
Complaint Details
The visit was triggered by a complaint related to a resident who fell and subsequently required hospital care and relocation to another facility. The complaint was self-reported by the facility and found to be appropriately handled.
Report Facts
Capacity: 230
Census: 176
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ito Chong | Assisted Living Director | Met with Licensing Program Analysts during the inspection |
| Ruth Martinez | Licensing Program Analyst | Conducted the inspection and interview |
Inspection Report
Annual Inspection
Census: 168
Capacity: 230
Deficiencies: 0
Jun 12, 2024
Visit Reason
The visit was an unannounced annual required inspection conducted by Licensing Program Analyst Ruth Martinez to evaluate compliance with regulations for the facility.
Findings
The inspection found no deficiencies in the areas inspected. The facility was observed to be well maintained with proper storage of medications and chemicals, adequate resident accommodations, functional safety systems, and complete resident and staff documentation.
Report Facts
Hospice residents: 15
Fire extinguisher service date: Jun 10, 2024
Pool fence height (inches): 70
Water temperature (degrees F): 117.6
Resident files reviewed: 10
Staff files reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the unannounced annual inspection |
| Geno Koehler | Executive Director | Met with Licensing Program Analyst during inspection and reviewed report |
Inspection Report
Complaint Investigation
Census: 162
Capacity: 230
Deficiencies: 0
Dec 27, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that residents need a higher level of care.
Findings
The investigation found no evidence to substantiate the allegation. Interviews with staff and residents, as well as care plan reviews, indicated that residents were receiving appropriate care and did not require a higher level of care.
Complaint Details
The complaint alleged that residents need a higher level of care. The investigation was unsubstantiated due to lack of preponderance of evidence to prove or refute the allegation.
Report Facts
Capacity: 230
Census: 162
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Armando J Lucero | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Ito Chong | Assisted Living Director | Met with the Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 167
Capacity: 230
Deficiencies: 0
Jun 14, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff were limiting residents' activities and delaying residents from accessing timely medical care.
Findings
The investigation found that the facility was following COVID-19 protocols as per Department PINs and allowed residents to leave for appointments with testing and isolation procedures in place. There was insufficient evidence to prove or refute the allegations, so the complaint was deemed unsubstantiated.
Complaint Details
The complaint alleged staff were limiting residents' activities and delaying access to timely medical care. The investigation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 230
Census: 167
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Geno Koehler | Administrator | Facility administrator interviewed during the investigation |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 167
Capacity: 230
Deficiencies: 0
Jun 14, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff did not adequately supervise a resident in the memory care unit.
Findings
The investigation included a virtual tour, file review, and interviews. The allegation was found to be unsubstantiated due to lack of corroborating evidence and witnesses, and the facility's security measures were described as adequate.
Complaint Details
The complaint alleged inadequate supervision of a resident in the memory care unit. The allegation was deemed unsubstantiated as there was insufficient evidence to prove or refute the claim.
Report Facts
Facility capacity: 230
Resident census: 167
Caregiver shifts: 3
Caregivers per shift: 3
Caregivers per shift: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Geno Koehler | Administrator | Facility administrator interviewed during the investigation |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 167
Capacity: 230
Deficiencies: 4
May 31, 2022
Visit Reason
An unannounced required annual inspection was conducted focusing primarily on Infection Control and compliance with regulatory requirements.
Findings
The facility appeared clean and sanitary with operational safety equipment and adequate supplies. Minor maintenance issues were noted such as broken light bulbs in three bathrooms and a grab bar in the elevator needing repair. No deficiencies were cited related to COVID-19 mitigation, but an advisory note was issued for follow-up corrections.
Deficiencies (4)
| Description |
|---|
| Single light bulbs in bathrooms of Apartments #141, #145, and #259 needed replacement. |
| Grab bar in the elevator needed repair. |
| Hand washing signs were missing in resident's bathrooms. |
| Required Department postings were not observed as they were being replaced. |
Report Facts
Residents in hospice care: 14
Licensed capacity: 230
Current census: 167
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Geno Koehler | Executive Director/Administrator | Met with Licensing Program Analysts during the inspection and named in the report. |
| Jessica Cho | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Edward Tapia | Licensing Program Analyst | Conducted the inspection. |
| Sheila Santos | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Annual Inspection
Census: 167
Capacity: 230
Deficiencies: 0
Jun 21, 2021
Visit Reason
Licensing Program Analyst Ruth Martinez conducted an unannounced required inspection visit to evaluate the facility's compliance with regulations.
Findings
The facility appeared clean, sanitary, and well-maintained with all required elements in place. No deficiencies were noted during the inspection per Title 22 Division 6 of the California Code of Regulations.
Report Facts
Hot water temperature: 115.4
Hot water temperature: 117.9
Medication supply delivery frequency: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the unannounced inspection visit |
| Ito Chong | Facility representative met during the inspection |
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