306004754-8-22-2022-22-AS-JCHO-CHJS6J-20220822133601

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004754
Report Date: 08/22/2022
Date Signed: 08/22/2022 01:36:23 PM

Document Has Been Signed on 08/22/2022 01:36 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 SANTA ANA MEMORY CARE		FACILITY NUMBER:	306004754
ADMINISTRATOR:	SANDRA ACOSTA-LOUER		FACILITY TYPE:	740
ADDRESS:	3730 S. GREENVILLE AVENUE		TELEPHONE:	(714) 641-0959
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92704
CAPACITY:	72	CENSUS: 36	DATE:	08/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Judith Torres		TIME COMPLETED:	01:55 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 08/22/2022, Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced visit to Crescent Landing at Santa Ana Memory Care. The purpose of today's visit was to conduct a Required 1 Year visit focusing primarily on the Infection Control. At 10:47am, LPA Cho was allowed entry into the facility and met with Executive Director (ED) Judith Torres after completing the Coronavirus 2019 (COVID-19) screening procedure. As of today, there are no active COVID-19 cases in the facility. Facility screens and documents temperatures for visitors on a sign in sheet. LPA did not observe the required COVID-19 precautionary signs posted on the front door and throughout the facility. ED indicated the signs will be back up after the facility has been repainted. The Complaint Posters (PUB475) were observed in the main lobby and the Staff Break Room in incorrect sizes. ED acknowledged to obtain the poster in the required sizing of 20"x26." The facility is licensed for 72 non-ambulatory residents and has a hospice waiver for 30. There are currently 36 residents living in the facility of which six are receiving hospice care. The Administrator's Certificate for Judith Torres expires on 07/15/2024. Around 10:58am, LPA Cho conducted a tour of the physical plant along with ED. There are 36 residents and 19 staff on site. LPA observed all staffs wearing PPE. LPA inspected the following common areas: Dining Room, Private Dining Room, Chart Room, Supply Room, Janitorial Room, Medication Room, Linen Room, Physical Therapy Room, TV Room, Storage Room, Kitchen, and Public Bathrooms. All common areas were clean and organized and found no health and safety issues. LPA randomly selected and inspected four resident bedrooms and bathrooms. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and the shared showers were free of mold/mildew. The tube lights in Bathroom A-1 needed to be replaced, and the four resident bathrooms were missing a trash can. Resident bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. ED acknowledged that the hand washing signs were not posted in all bathrooms.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022

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 7

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 SANTA ANA MEMORY CARE	FACILITY NUMBER: 306004754
	VISIT DATE: 08/22/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA Cho tested the hot water temperature in the resident bathrooms and the temperatures measured at 106.1 degrees Fahrenheit in the Bathroom #1, 120.0 degrees Fahrenheit in Bathroom #2, 102.9 degrees Fahrenheit in Bathroom #3, and 80.9 degrees Fahrenheit in Bathroom #4. The fire extinguishers was fully charged. The smoke and carbon monoxide detectors were serviced by Cal Building Systems on 02/15/2022. Medications, toxins, and sharps were locked and inaccessible to the residents. LPA Cho toured the outside grounds. There were no bodies of water present. There was shading and sufficient seating for residents. Walkways were clear of hazards, and the exit gates were self-closing and self-latching. There were no security bars or weapons on the premises. Facility does have back-up emergency food and water supply in the Kitchen and Storage Room. The First Aid Kit met all the required components including the first aid manual, and the facility had sufficient PPEs

No resident or staff files were reviewed at the time of this visit. LPA reviewed the COVID-19 mitigation plan of the facility. The facility does have an existing internet service and provides an iPad upon request per Assembly Bill (AB) 665. Facility has the outdated Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E). ED is aware and agrees to update the information using the revised LIC610E form.

LPA provided the following guidance to ED Judith Torres: to enlarge and post the Complaint Poster (PUB475) in the required sizing of 20"x26," to obtain and post hand washing signs in all shared bathrooms, to repair the tube light in A-1's Bathroom, to obtain trash cans for the resident bathrooms, and to maintain hot water temperature within regulations. As a reminder, LPA discussed the importance of staying abreast with CCLD's COVID-19 guidance by reviewing and printing the Provider Information Notices (PINs) as well as by attending the CCLD Informational Calls. The PINs can be accessed at: www.ccld.ca.gov. ED indicated the Infection Control Plan (LIC9282) and the Emergency Infection Control Plan pertaining to Monkeypox guidelines will be submitted by 08/26/2022 along with the updated LIC610E.

Based on the observations made during today's visit, a deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. Advisory Notes (LIC9102) were issued during the visit. An exit interview was conducted with Executive Director Judith Torres, and a copy of this report (LIC809, LIC809C, LIC809D, LIC9102s, along with the appeal rights) were provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022

LIC809 (FAS) - (06/04)

Page: 2 of 7

Document Has Been Signed on 08/22/2022 01:36 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 SANTA ANA MEMORY CARE	FACILITY NUMBER: 306004754
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(2)

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, hot water measured below 105 degrees Fahrenheit for two out of the four bathrooms which poses a potential Health, Safety, or Personal Rights risk to persons in care.
	POC Due Date: 08/30/2022
	Plan of Correction
1 2 3 4	Licensee/Executive Director agrees to readjust the water temperature and take water temperatures three times per day on a 7 day log effective 08/23/2022 and ending on 08/30/2022. Licensee to submit the proof of correction to LPA via email by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022

LIC809 (FAS) - (06/04)

Page: 3 of 7