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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005316
Report Date: 11/15/2024
Date Signed: 11/15/2024 05:14:26 PM

Document Has Been Signed on 11/15/2024 05:14 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ANAHEIM CROWN PLAZAFACILITY NUMBER:
306005316
ADMINISTRATOR/
DIRECTOR:		KIM N KINCAIDFACILITY TYPE:
740
ADDRESS:641 SOUTH BEACH BLVDTELEPHONE:
(714) 827-7007
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 200CENSUS: 144DATE:
11/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:29 AM
MET WITH:Jerry Rodriguez- AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPAs) Dwayne Mason Jr. and Nancy Guillen arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPAs were greeted at the facility by facility staff. LPAs met with Jerry Rodriguez, Administrator and explained the purpose of the inspection.

The facility is three-story building with 107 resident rooms. The first floor houses 34 resident rooms as well as a family room, lobby, reception area, administrative office, break room, medication room, laundry rooms and kitchen. The second floor houses 37 resident rooms, maintenance office, beauty shop and break room. The third floor houses 36 resident rooms, break room, activity office, library and temporary office space.

All resident rooms had the required elements, including bed, chair, closet space and ample lighting. Facility has toxins, chemicals and cleaning supplies locked in storage closets on the second floor. Restrooms are stocked with soap and paper towels. Hot water measured between 105 and 120 degrees F. LPA observed facility has emergency food and water supply as well as additional emergency supplies. LPAs reviewed six staff files and ten resident files. LPAs conducted interviews with ten residents and three staff. LPAs reviewed medication. Based on medication review. LPAs determined facility staff could not locate two PRN medications prescribed to one resident and one non-PRN medication prescribed to a different resident. LPAs also observed missing signatures on multiple Medication Administration Records. Three deficiencies are being issued. LPAs observed two PRN medications prescribed to one resident that had hand-written labels taped over the printed labels. Facility Staff stated they created the labels when the physician's order changed for the PRN medications. Facility staff called the pharmacy and verified the information written on the label was correct. LPAs advised facility staff of regulations prohibiting handwriting or altering prescription labels. A technical violation was issued.

Based on today's inspection, three deficiencies and one technical violation are being issued. An exit interview was conducted and a copy of this report and appeal rights were provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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 3
Document Has Been Signed on 11/15/2024 05:14 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 11/15/2024 at 04:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ANAHEIM CROWN PLAZA
FACILITY NUMBER: 306005316

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(1)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medication review, the licensee did not comply with the section cited above due to being unable to locate 3 presribed medications for residents during the inspection. This poses a potential health risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Administrator stated they will conduct an in-service training with all medication staff. AD stated they will email LPA documentation of the training including the staff in attendance, date/time of the training and the content covered during the training. AD stated they will email the aforementioned to LPA by the assigned POC due date.
Type B
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medication review, the licensee did not comply with the section cited above due to multiple Medication Administration Records missing signatures for doses given to residents. This poses a potential health risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Administrator stated they will conduct an in-service training with all medication staff. AD stated they will email LPA documentation of the training including the staff in attendance, date/time of the training and the content covered during the training. AD stated they will email the aforementioned to LPA by the assigned POC due date.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/15/2024 05:14 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 11/15/2024 at 04:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ANAHEIM CROWN PLAZA
FACILITY NUMBER: 306005316

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medication review, the licensee did not comply with the section cited above due to multiple Medication Administration Records missing signatures for PRN doses given to residents. This poses a potential health risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Administrator stated they will conduct an in-service training with all medication staff. AD stated they will email LPA documentation of the training including the staff in attendance, date/time of the training and the content covered during the training. AD stated they will email the aforementioned to LPA by the assigned POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


LIC809 (FAS) - (06/04)
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