306005316-8-4-2025-22-AS-HGOH-DK8VNG-20250804163506

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005316
Report Date: 08/04/2025
Date Signed: 08/04/2025 04:35:17 PM

Document Has Been Signed on 08/04/2025 04:35 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ANAHEIM CROWN PLAZA		FACILITY NUMBER:	306005316
ADMINISTRATOR/ DIRECTOR:	KIM N KINCAID		FACILITY TYPE:	740
ADDRESS:	641 SOUTH BEACH BLVD		TELEPHONE:	(714) 827-7007
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY: 200		CENSUS: 129	DATE:	08/04/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Jerry Rodriguez		TIME VISIT/ INSPECTION COMPLETED:	04:50 PM

NARRATIVE

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Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Jerry Rodriguez and discussed the purpose of the visit. The facility currently has 139 residents in care.

The facility is a three story building with resident apartments, 2 activities rooms, dining room, laundry rooms, kitchen, staff offices, and medication room. The facility appears clean, safe, and sanitary. LPA observed residents engaging in an ice cream social in the activity room at the time of the inspection. LPA observed the required departmental postings throughout the facility. LPA observed the resident apartments to have the required components and furnishings. LPA observed the resident bathrooms to have soap, toilet paper, and non-slip mats. LPA tested the water to be between 115.1-122.5 degrees Fahrenheit in the resident bathrooms. LPA observed the dining room between food services while staff was cleaning and preparing for the next seating. LPA observed the kitchen to be clean and free of vermin. LPA observed the kitchen doors to lock making the knives inaccessible to residents in care when not in use. LPA observed the emergency food and water supply in a closet located in the kitchen. LPA observed a seven day nonperishable and two day perishable food supply on hand. LPA observed fire extinguishers in the kitchen and throughout the facility charged and with service dates of September 5, 2024. LPA observed the medication room to have a lock making it inaccessible to residents in care. LPA observed the laundry rooms for staff to be locked and the resident laundry room to be operational. LPA observed toxins and chemicals to be in a closet located in the kitchen and in a closet on the second floor. LPA observed the courtyard to be free of debris and obstructions and has a shaded seating area for resident use.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Hanna Gough
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 08/04/2025 04:35 PM - It Cannot Be Edited

Created By: Hanna Gough On 08/04/2025 at 03:44 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: 08/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(2)

87303(e)(2) Maintenance and Operation 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 This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in one resident restroom water testing at 122.5 degrees Farenheit which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/01/2025
	Plan of Correction
1 2 3 4	Licensee stated they will fix the water temperature and test it for 3 consecutive days and send proof to LPA 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.

	Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:

	Hanna Gough
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/04/2025 04:35 PM - It Cannot Be Edited

Created By: Hanna Gough On 08/04/2025 at 04:07 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: 08/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 out of 5 staff trainings which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/01/2025
	Plan of Correction
1 2 3 4	Licensee stated they will have staff take trainings and send proof to LPA 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.

	Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:

	Hanna Gough
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ANAHEIM CROWN PLAZA	FACILITY NUMBER: 306005316
	VISIT DATE: 08/04/2025

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LPA reviewed resident files and no discrepancies were observed. LPA reviewed resident medications and no discrepancies were observed. LPA reviewed staff files and 3 of 5 staff do not have the required annual training's. LPA observed the last fire drill was conducted on July 21, 2025. LPA reviewed an annual report by Cal Fire dated October 31, 2024, stating that the fire alarms were tested and passed inspection. All staff present are background cleared and associated to the facility.

Based on today’s observations two deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with AD Jerry Rodriguez and a copy of this report along with LIC 809-D, LIC 859,LIC 811 and appeal rights were given at the time of inspection.

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Hanna Gough
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025

LIC809 (FAS) - (06/04)

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