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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607753
Report Date: 08/27/2026
Date Signed: 08/27/2026 01:40:55 PM

Document Has Been Signed on 08/27/2026 01:40 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CROWN MANORFACILITY NUMBER:
197607753
ADMINISTRATOR/
DIRECTOR:		KEVIN MATTHEW BIMFACILITY TYPE:
740
ADDRESS:15327 CAMPILLOS ROADTELEPHONE:
(714) 743-7516
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 6CENSUS: 5DATE:
08/27/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:24 AM
MET WITH:Kevin Bim, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) N. Galarza arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual evaluation. LPA was greeted and granted entry by caregiver staff. Administrator Kevin Bim arrived later on to assist with inspection. Administrator has a valid administrator's certificate expiring on 6/8/2027.

The following was observed during the inspection:

Infection Control: The Infection Control Plan includes Environmental cleaning and disinfection activities.

Operational Requirements: A Dementia and hospice waiver for 3 residents has been approved. A fire clearance for 5 non-ambulatory adults 60 and over; and one (1) may be bedridden resident. Facility does not handle resident P & I monies. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current.

Physical Plant/Environment Safety: The interior and exterior physical plant was inspected. The facility is a single-story home located in a residential area consisting of three (3) resident bedrooms, one (1) live-in staff room, two (2) full bathrooms, kitchen, dining room, living room, laundry room, detached garage, and a covered backyard patio area. Rooms are equipped with required furniture, bedding and mattress pads. Cleaning supplies and toxic substances are inaccessible to residents. The facility has a fire extinguisher. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Smoke and carbon monoxide detectors were tested and are operational. The facility maintains emergency food supply and water. Emergency Phone numbers, exit plan and programming schedules were posted. The facility has central air conditioning and heating. First aid kits/Manuals are kept in activity rooms; consisting of thermometer, tweezers, scissors, antiseptic, bandages, gauze. Exit doors are free of any obstruction. The last Emergency Disaster drill was conducted on 7/13/2026.

Lisa Hicks
Noemi Galarza
DATE: 08/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CROWN MANOR
FACILITY NUMBER: 197607753
VISIT DATE: 08/27/2026
NARRATIVE
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Staffing: A total 4 staff members provide care and supervision to the residents.

Personnel Records/Staff Training: Four (4) staff files were reviewed. Proof of staff training, health clearance, and 1st Aid/CPR training is current in files. Staff have criminal background clearance. Staff (S4) is not associated to the facility. A citation/civil penalty was issued.

Resident Records/Incident Reports: A total of five (5) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent. However, residents R1, R3 and R4's Medical Assessments and Appraisals are not current. Citations were issued.

RCFE complaint poster and Personal rights were observed posted.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. The facility does not have a Resident Council.

Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Four residents have modified diets.

Incident Medical and Dental: Centrally stored / 30-Day supply of medications were reviewed. Medical and dental transportation is provided by family. *There were 3 unlocked medication bottles without a label on top of the kitchen table, staff stated they belonged to R1 and are transferred when the medications are not administered. A citation was issued.

Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual.

Residents with Special Health Needs: No residents are currently enrolled in hospice services, two (2) residents receive home health services, one resident has a prohibited health condition (g-tube), and one resident is bedridden. A citation was issued.

Pursuant to Title 22, deficiencies were observed and are cited.


An exit interview was conducted with Administrator Kevin Bim. A copy of the report/appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/27/2026 01:40 PM - It Cannot Be Edited


Created By: Noemi Galarza On 08/27/2026 at 12:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CROWN MANOR
FACILITY NUMBER: 197607753

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that staff (S4) is not associated to the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2026
Plan of Correction
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Administrator agreed to associate staff (S4) to the facility via Guardian. Submit proof of correction.
Civil penalty was assessed.
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that there were 3 unlocked medication bottles without a label on top of the kitchen table, staff stated they belonged to R1 and are transferred to bottles without labels when the medications are not adminestered and R1's levetiracetam 100mg/ml solution and daily liquid multi-vitamins were unlocked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2026
Plan of Correction
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Administrator agreed to submit a written plan of correction and proof of staff training regarding Title 22 regulation 87465.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/27/2026 01:40 PM - It Cannot Be Edited


Created By: Noemi Galarza On 08/27/2026 at 12:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CROWN MANOR
FACILITY NUMBER: 197607753

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that R2's bed has full bed rails, but R2 is not enrolled in hospice services; additionally, R1's bed has three-quarter length bed rail, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2026
Plan of Correction
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Licensee/Administrator removed R2's full bed rails and R1's three-quarter length bed rails during the visit. Submit copies of R1 & R2's half length bed rail physician order.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/27/2026 01:40 PM - It Cannot Be Edited


Created By: Noemi Galarza On 08/27/2026 at 12:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CROWN MANOR
FACILITY NUMBER: 197607753

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that residents (R1, R3 & R4's) appraisals are over 12 months old, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2026
Plan of Correction
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Administrator agreed to submit copies of R1, R3, and R4's appraisals.
Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that residents (R1, R3 & R4's) Medical Assessments are more than 12 months old, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2026
Plan of Correction
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Administrator agreed to submit updated copies of R1, R3 and R4's Medical Assessments.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/27/2026 01:40 PM - It Cannot Be Edited


Created By: Noemi Galarza On 08/27/2026 at 01:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CROWN MANOR
FACILITY NUMBER: 197607753

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87615(a)(2)
Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (2) Gastrostomy tubes.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that R1 has a prohibited health condition (G-Tube), which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2026
Plan of Correction
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Administrator agreed to submit a written plan that includes understanding that a facilty may not retain or accept residents with prohibited health conditions, contact R1's physician, and submit a relocation plan to a higher level of care facility if applicable.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2026


LIC809 (FAS) - (06/04)
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