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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004753
Report Date: 11/07/2022
Date Signed: 11/07/2022 01:33:50 PM


Document Has Been Signed on 11/07/2022 01:33 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: 39DATE:
11/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Louis StevensonTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on a death report received by Community Care Licensing on 10/31/2022. LPA was greeted and granted entry into the facility by Health Service Director Louis Stevenson and explained the reason for the visit.

Death report dated 10/30/2022 indicated Resident 1 (R1) was discovered to be unresponsive by caregiver. Caregiver arrived to assist resident to breakfast when discovered around 7:55 AM. Caregiver notified med tech on duty and 911 was called. Facility did not start CPR as resident had a "Do not resuscitate" on file. Paramedics and police responded shortly thereafter and resident was declared deceased. Officer advised facility to make contact with mortuary. Resident was last observed by a caregiver around 430 AM with no concerns noted. Resident had been under the care of a physician due to congestion and cold symptoms and had been prescribed Benzonatate for cough suppression. Prior to the episode of congestion, R1 was assessed by a physician on 08/25/2022 and was diagnosed with Hypertension, Diabetes, and Hyperlipidemia. Physician report dated 04/19/2022 indicated a diagnosis of Dementia. R1 was prescribed three medications for Hypertension and one medication for Hyperlipidemia.

Facility to forward a copy of death certificate to LPA once received.




No deficiencies noted during today's visit.
Exit interview conducted and a copy of this report was left with facility representative.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
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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