306004447-6-23-2022-22-AS-JHAY-CFNSAW-20220623134300

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004447
Report Date: 06/23/2022
Date Signed: 06/23/2022 01:43:05 PM

Document Has Been Signed on 06/23/2022 01:43 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	CRESCENT RESIDENTAL HOME		FACILITY NUMBER:	306004447
ADMINISTRATOR:	LAUREN LU		FACILITY TYPE:	735
ADDRESS:	7150 CRESCENT AVENUE		TELEPHONE:	(714) 761-2695
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY: 6		CENSUS: 6	DATE:	06/23/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:18 PM
MET WITH:	Jenalou Cadampog		TIME COMPLETED:	01:50 PM

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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit.

Administrator Lauren K. Lu has a current administrator certificate that expires 11/18/22. The facility had all the required postings on the wall. LPA Haley observed a screening station with a temperature log book, temperature thermometer and hand sanitizer near the entrance of the facility. There were six residents present for the visit.

LPA Haley began the tour with Staff at 12:40. We started the tour of the facility in the locked staff office. There was a locked medication cabinet, and above there was a locked cabinet with resident hygiene products. Client files were also neatly organized in the cabinets in the staff office. LPA Haley observed a first aid kit equipped with all the required elements. Further, the facility has adequate PPE supply of gloves, N95 mask, surgical mask, and hand sanitizers stored in the staff office as well.

The garage was organized and free of clutter. There was a locked cabinet with cleaning materials. There was an additional supply of food items stored in the garage, along with a emergency supply of water. The facility has emergency kits and emergency bags prepared and ready to go for each resident.

The kitchen was clean and well organized. All knives and sharp objects were locked in a drawer. The stove was clean and all burners were operational. The facility has a two day supply of perishable food items and seven day supply of nonperishable food items that are kept orderly and organized.

At 12:55 LPA Haley began the tour of resident rooms and bathrooms. All client bedrooms were clean, well organized, and had all necessary requirements: night stand, chair, lamp and storage space. Both client bathrooms were clean and organized. Hot water temperature was measured at 106.3 degrees Fahrenheit in client bathroom #1 and 111.5 degrees Fahrenheit in client bathroom #2.

CONTINUED ON LIC 809C DATED 06/23/2022.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CRESCENT RESIDENTAL HOME	FACILITY NUMBER: 306004447
	VISIT DATE: 06/23/2022

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LPA Haley and staff toured the back yard and it was clean and free of clutter. There was a side exit gate that was self closing and self latching. There was a shaded area with a table and chairs. LPA Haley observed plenty of games, entertainment and activities for the residents to enjoy. There were no bodies of water observed.

All smoke detectors were tested and are operational. The fire extinguisher was mounted in the kitchen and charged. No deficiencies are being cited during todays visit.

An exit interview conducted and a copy of the report was provided to the Administrator Lauren Lu.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022

LIC809 (FAS) - (06/04)

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