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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004753
Report Date: 09/06/2022
Date Signed: 09/06/2022 11:45:47 AM


Document Has Been Signed on 09/06/2022 11:45 AM - 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: DATE:
09/06/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Darlene LopezTIME COMPLETED:
12:10 PM
NARRATIVE
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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 08/31/2022. LPA was greeted and granted entry into the facility by Business Office Manager Darlene Lopez and explained the reason for the visit.

Incident report dated 08/30/2022 indicated facility received a phone call from Garden Grove Police around 2:15 PM stating the resident was with them. R1 was assisted back to the facility and assessed to have no injuries. Facility investigation revealed the resident had been in the secured courtyard alone prior to the elopement. Per video surveillance, R1 climbed over the back fence at 1:20 PM. Staff did not notice the resident was missing and last contact was at 1PM by facility staff. Facility has installed a bush where the resident stepped to climb the fence. R1 admitted under respite care on 07/08/2022 and admitted as a regular resident on 08/07/2022. Physician report dated 06/23/2022 indicates a diagnosis of Dementia and wandering tendencies. Resident has had no prior incidents at the facility.

During the visit, LPA toured the courtyard and common area of facility. LPA attempted to speak with R1 during the visit. Resident is unable to answer LPA's questions but appeared clean and engaging with other residents.


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 Business Office Manager 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: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2022
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 09/06/2022 11:45 AM - 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: 09/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/07/2022
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 record review and interview conducted, facility failed to ensure resident was provided care and supervision. R1 eloped out of the facility and staff were notified by Garden Grove Police. Per physician report, R1 has a history of wandering. 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: 09/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2