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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005316
Report Date: 10/12/2021
Date Signed: 10/13/2021 01:03:58 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 PLAZAFACILITY NUMBER:
306005316
ADMINISTRATOR:JOHNSON, CAMMYFACILITY TYPE:
740
ADDRESS:641 SOUTH BEACH BLVDTELEPHONE:
(714) 827-7007
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:200CENSUS: 137DATE:
10/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:01 PM
MET WITH:Cammy JohnsonTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Lydia Martinez conducted an unannounced visit for the purpose of conducting a Required - 1 Year evaluation. LPA was greeted and granted entry into the facility by LVN Gerardo Rodriguez. Administrator Cammy Johnson arrived shortly after and reason for visit was explained. Administrator Johnson has a current Administrator Certificate which expires on 12/17/2021.

LPA toured the facility with AD Johnson. Facility has 137 residents in care during today's visit. LPA observed residents relaxing in common areas of the facility and in their room. All residents appeared happy and well taken care of. Facility appears clean and sanitary. Facility screens all visitors to the facility and LPA observed the screening/sanitizing station in the entrance of the facility. Facility takes resident and staff temperatures daily and documents. Facility has COVID precaution postings as well as required Department postings. Mitigation Plan has been received and approved. All resident rooms had the required elements including restrooms stocked with soap/sanitizer. LPA observed ample emergency food and water as well as multiple First Aid kits throughout the facility. LPA observed a shaded outside visitation area. Fire Extinguishers are mounted and charged. Facility has an ample supply of PPE, incontinence, and cleaning supplies. Facility has a plan for COVID testing residents and staff as needed as well as a plan for isolation. All resident emergency information has been updated. Most residents and all staff are vaccinated for COVID-19.

No deficiencies noted during today's visit. Exit interview conducted and a copy of this report will be provided via email.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
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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