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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004754
Report Date: 11/30/2023
Date Signed: 11/30/2023 10:08:17 AM


Document Has Been Signed on 11/30/2023 10:08 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 SANTA ANA MEMORY CAREFACILITY NUMBER:
306004754
ADMINISTRATOR:SANDRA ACOSTA-LOUERFACILITY TYPE:
740
ADDRESS:3730 S. GREENVILLE AVENUETELEPHONE:
(714) 641-0959
CITY:SANTA ANASTATE: CAZIP CODE:
92704
CAPACITY:0CENSUS: 49DATE:
11/30/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Judith Torres- Executive DirectorTIME COMPLETED:
10:10 AM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho conducted the Case-Management- Deficiencies visit in conjunction with the delivery of the findings for a complaint investigation in connection to Complaint Control Number: 22-AS-20201109104853. LPA met with Executive Director (ED) Judith Torres and explained the reason for the visit.

During the investigation into the complaint investigation mentioned above, the following violations were observed: Resident #1’s (R1’s) Responsible Person (RP) was not immediately informed of the changes as required per the Title 22 Regulations, 87463 Reappraisals. RP was not immediately notified regarding R1’s diet changes.

Additionally, the facility placed (4) doctor’s orders to R1’s primary care physician requesting a swallow evaluation and a modified diet. Facility did not have an existing doctor’s order approving the modified diet. R1 was placed on a temporary puree diet as it was noted on the initial doctor’s order form. LPA did not observe any approved orders prescribed by the primary care physician approving the modified diet following the requests.

Deficiencies are being cited per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. See the attached LIC809-D.

An exit interview was conducted with Executive Director Judith Torres, and a copy of this report including the LIC809-D, LIC811, and the appeal rights were provided at the end of the visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
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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Document Has Been Signed on 11/30/2023 10:08 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 SANTA ANA MEMORY CARE
FACILITY NUMBER: 306004754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/07/2023
Section Cited
CCR
87463(b)

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87463 Reappraisals (b) The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person.
This requirement was not met as evidenced by:
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Executive Director stated that she will submit a proof of staff training and an Acknowledgement of Understanding for the cited deficiency to LPA by POC due date.
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Based on LPA’s interviews and review of records, the facility did not immediately inform the change of condition to R1’s responsible person which poses a potential Health, Safety, and Personal Rights risk to persons in care.
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Type B
12/07/2023
Section Cited
CCR87555(b)(7)

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87555 Food Service Requirements (b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided.
This requirement was not met as evidenced by:
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Exectutive Director stated that she will submit a proof of staff training and an Acknowledgement of Understanding for the cited deficiency to LPA by POC due date.
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Based on LPA’s interviews and review of records, the facility did not have a doctor’s order prescribing the modified diet which poses a potential Health, Safety, and Personal rights risk to persons 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: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
LIC809 (FAS) - (06/04)
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