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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004753
Report Date: 07/05/2022
Date Signed: 07/05/2022 02:30:49 PM


Document Has Been Signed on 07/05/2022 02:30 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 LANDING AT GARDEN GROVE MEMORY CAREFACILITY NUMBER:
306004753
ADMINISTRATOR:JESUS SOTO FLORESFACILITY TYPE:
740
ADDRESS:11848 VALLEY VIEW STREETTELEPHONE:
(714) 895-9898
CITY:GARDEN GROVESTATE: CAZIP CODE:
92845
CAPACITY:72CENSUS: 27DATE:
07/05/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Jesus SotoTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident report received by Community Care Licensing on 07/04/2022. LPA was greeted and granted entry into the facility by Executive Director Jesus Soto and explained the reason for the visit.

Incident report dated 07/04/2022 indicated Resident 1 (R1) had been given seven of R2's morning medications. Physician was notified and resident was monitored every hour for blood pressure. R1 had no adverse effects from the medication. Per physician report dated 03/24/2022, R1 is diagnosed with Dementia. Facility investigation revealed that Staff 1 (S1) had attempted to administer medications to R2 but the medications were refused. S1 returned the medications to the med cart. Medications were in a cup. Staff inadvertently gave the medication to R1 and failed to employ the normal safeguards to ensure medications are administered to the correct resident. Per Administrator, S1 will be provided corrective action to ensure accountability for the error.

During the visit, LPA toured the facility and spoke with both R1 and R2. Both residents were in the dining room and appeared happy and well taken care of.


Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with Administrator and a copy was provided as well as appeal rights.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 07/05/2022 02:30 PM - It Cannot Be Edited

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 LANDING AT GARDEN GROVE MEMORY CARE
FACILITY NUMBER: 306004753

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/06/2022
Section Cited

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Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not being met as evidenced by:
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Based on interview and record review, Licensee failed to ensure care was provided to R1. R1 received seven of R2's morning medications. This poses an immediate health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2