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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607753
Report Date: 09/25/2023
Date Signed: 09/25/2023 04:57:17 PM


Document Has Been Signed on 09/25/2023 04:57 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:CROWN MANORFACILITY NUMBER:
197607753
ADMINISTRATOR:KEVIN MATTHEW BIMFACILITY TYPE:
740
ADDRESS:15327 CAMPILLOS ROADTELEPHONE:
(714) 743-7516
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY:6CENSUS: 5DATE:
09/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Administrator Kevin BimTIME COMPLETED:
11:50 AM
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Licensing Program Analyst/ (LPA) Jose Villalobos conducted an unannounced annual inspection visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was by staff Gloria Romulo and the purpose of the visit was discussed. Administrator Kevin Bim arrived shortly after.

Structure/Physical Plant: The facility is licensed for six (6) residents age 60 and over, of which may include (5) non-ambulatory residents, (1) bedridden, and (3) hospice care. The facility is a one story house located in a residential neighborhood consists of front and backyard, (3) resident bedrooms, (2) resident bathrooms, (1) staff room, family room, dining room, kitchen, attached garage/ storage area, enclosed patio with table and chairs. Facility has central air and heating as well as a washer and dryer Accommodations: Adequate accommodations observed throughout facility. Hallway and Doorways: Free and clean of obstruction and debris. Resident Rooms: All bedrooms are equipped with: overhead lighting, chair, night stand, lamp in addition to overhead lighting, large drawer, and closet space. Bathrooms: All bathrooms have a working toilet, wash basin, shower, grab bars and nonskid mats. Linens & Hygiene Supplies: Required linen/supplies observed. Emergency Phone Numbers, Exit Plan & Menu: Facility has a working phone landline. There is a cordless phone for client use. Fire Extinguishers observed Food Service: All food and adequate utensils such as, dishes, cups, bowls and plates observed. Supply of perishables and non-perishables observed. Smoke Detectors & Fire Extinguishers: Detectors Electrical & connected. All detectors operational. Toxins: Locked/stored for staff use only. Hot Water Temperature: Measured between 110 -115 degrees all around the home. Medications, First-Aid Kit & Book: Medications centrally stored and inaccessible to residents. First aid kit observed. Postings: Wall postings observed. Residents & Staff Files: LPA reviewed (5) of (5) resident medication records and files , as well as three (3) Staff Files . Emergency Disaster, Infection Control, and Plan of Operation also observed and reviewed.

Inspection tool completed and no deficiencies are being cited. Exit Interview conducted and a copy of this report was provided
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2023
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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