306005316-12-9-2020-22-AS-MRED-BW62NM-20201209163258

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005316
Report Date: 12/09/2020
Date Signed: 12/09/2020 04:33:36 PM

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:	ANAHEIM CROWN PLAZA		FACILITY NUMBER:	306005316
ADMINISTRATOR:	JOHNSON, CAMMY		FACILITY TYPE:	740
ADDRESS:	641 SOUTH BEACH BLVD		TELEPHONE:	(714) 827-7007
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY:	200	CENSUS: 123	DATE:	12/09/2020
TYPE OF VISIT:	Case Management - Other	ANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Licensee Kim Kincaid and Administrator Cammy Johnson		TIME COMPLETED:	01:00 PM

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Licensing Program Analyst (LPA) Michelle Reed conducted an announced visit to the facility for the purpose of conducting a TAP Visit with Orange County Public Health (OCPH). Upon arrival, LPA met with RN April Anderson and Infection Control Specialist and RN Larry Bottorff. Mr. Bottorff is from Expert Stewardship. Licensee Kim Kincaid and Administrator Cammy Johnson were also present.

The visit was conducted to protect staff and residents and to mitigate the spread of COVID19. The OCPH staff provided training on the prevention, transmission (eyes, nose, mouth) and symptoms of COVID as well as proper use of PPE. Hand washing, donning and doffing and disinfection of the facility were also discussed. It was recommended that direct care staff wear N95 masks if fitted along with a face shield. KN95’s could also be used. Residents should also be encouraged to wear face masks if possible. Disinfecting of facility surfaces should be completed every 2 to 4 hours.

A tour of the facility was conducted to develop a mitigation plan with facility staff. The plan developed by OCPH includes a red zone on the second floor (for positive residents) as well as yellow zone rooms and a green zone for non-covid residents. Staff will have their own restroom and breakroom in the red zone. Residents in the red zone will be quarantined for 21 days and then move back to the yellow or green zone. These mitigation measures were provided to assist with keeping asymptomatic COVID positive residents at the facility and help to open skilled nursing and hospital beds for people with serious health conditions. Community Care Licensing (CCLD) supports the mitigation plan that was developed.

Licensee Kim Kincaid and Administrator Cammy Johnson reported that they will support the mitigation plan and work with OCPH and CCL. (Continued)

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2020

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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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: ANAHEIM CROWN PLAZA	FACILITY NUMBER: 306005316
	VISIT DATE: 12/09/2020

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Licensee Kim Kincaid is working on readmitting residents back into the facility from skilled nursing and will keep her LPA updated.

The facility currently has enough staffing and an ample supply of PPE and will reach out to CCL if needed. An exit interview was conducted at the time of visit with Kim Kincaid and a copy of this report was provided via email for signature. An electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2020

LIC809 (FAS) - (06/04)

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