197607753-8-23-2024-28-AS-EZAA-D8ER3K-20240823124005

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607753
Report Date: 08/23/2024
Date Signed: 08/23/2024 12:40:26 PM

Document Has Been Signed on 08/23/2024 12:40 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	CROWN MANOR		FACILITY NUMBER:	197607753
ADMINISTRATOR:	KEVIN MATTHEW BIM		FACILITY TYPE:	740
ADDRESS:	15327 CAMPILLOS ROAD		TELEPHONE:	(714) 743-7516
CITY:	LA MIRADA	STATE: CA	ZIP CODE:	90638
CAPACITY:	6	CENSUS: 5	DATE:	08/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:33 AM
MET WITH:	Aissa Madrid - Caregiver		TIME COMPLETED:	12:50 PM

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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Aissa Madrid, caregiver for the facility, and explained the purpose of the visit. Administrator Kevin Bim arrived shortly thereafter. There are four (4) non-ambulatory and one (1) bedridden residents residing within the home.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

Infection Control:

· Infection control practices were observed.

· Infection control plan is on file.

Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood. It is licensed for a capacity of six (6) residents, one (1) of which may be bedridden and the remaining five (5) may be non-ambulatory, as well as a hospice waiver approved for three (3) residents. The facility consists of a kitchen and dining room which contains the facility’s washer and dryer machines, a living room, four (4) resident bedrooms, a backyard area, and two (2) resident bathrooms of which Restroom #1 (R1) had a hot water temperature reading of 107.4 degrees Fahrenheit, and Restroom #2 measured at 109.9 degrees Fahrenheit. The facility was observed to be in good repair.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CROWN MANOR	FACILITY NUMBER: 197607753
	VISIT DATE: 08/23/2024

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·The interior and exterior physical plant was inspected. Exit doors are free of any obstruction.
· Water temperature readings for one of the bathrooms in the home did not fall within the required range of 105 - 120 degrees Fahrenheit.

Operational Requirements:

· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for a capacity of six (6) residents, one (1) of which may be bedridden and the remaining five (5) may be non-ambulatory, as well as a hospice waiver approved for three (3) residents.

· Care and supervision to meet the clients’ needs was observed.

Staffing:

· Three (3) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Three (3) staff files were reviewed for criminal background clearance and training.

· All staff records reviewed have health a health screening with a Tuberculosis clearance, and all staff have First Aid/CPR trainings that are active.
· The administrator’s certificate expires on 6/8/2025.

Resident Rights/Information:

· Physician orders were reviewed for five (5 resident files.

· Medications were also reviewed for five (5) residents.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CROWN MANOR	FACILITY NUMBER: 197607753
	VISIT DATE: 08/23/2024

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Resident Records/Incident Reports:
· Five (5) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed.

Food Service:

· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

Incident Medical and Dental:

· All residents have an Appraisal/Needs and Services Plan on file

· Staff training was on file.

Disaster Preparedness:

· Emergency and Disaster Plan was publicly posted and found within the facility.

· The last emergency and disaster drill was conducted on 6/12/2024.

Planned Activities:

· Sufficient Space is provided to accommodate both indoor and outdoor activities.

· Sufficient equipment and supplies are provided to meet the requirements of the activity program.

Residents with Special Health Care Needs:

· There are three (3) residents who receive services from home health agencies, and the facility has the agreement with the home health agencies documented and on file.

· There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed during the visit. Exit interview held and a copy of the report was provided.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

LIC809 (FAS) - (06/04)

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