306005316-9-15-2022-22-AS-RQUZ-CJAPEV-20220915111547

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005316
Report Date: 09/15/2022
Date Signed: 09/15/2022 11:16:31 AM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/15/2022 11:16 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:	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: 141	DATE:	09/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Cammy Johnson, Administrator		TIME COMPLETED:	11:15 AM

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On today’s date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Quiroz was greeted, COVID-19 screened and granted entry into the facility by Front desk Receptionist. LPA Quiroz met with Administrator Cammy Johnson and explained the nature of the visit.

This facility is licensed to provide services to Elderly residents age range 60 and over. Approved for 200 Ambulatory residents, of which 142 may be Non-Ambulatory and has an approved hospice waiver for 20 residents. The facility is currently providing services to (2) two Hospice residents at this time.

Administrator Cammy Johnson has an Administrator certificate with expiration date of 12/17/2023. On today's date, LPA Quiroz along with (AD) Cammy Johnson toured the inside and outside of facility. All staff working at facility were observed to be wearing face masks upon arrival to facility. There are one hundred and forty one (141) residents in care and there are no active COVID-19 cases.

On or about 10:17am, LPA Quiroz along with (AD) Johnson and Facility Cook toured the kitchen area. LPA Quiroz observed variety of fresh fruits and vegetables in kitchen area and plentiful amount of perishable and non-perishable food items. Five of five staff in kitchen area were observed to be wearing their face masks.

During today's inspection visit, LPA Quiroz observed residents in Activity room on first flour, in lounge area on third floor, in smoking designated areas, in their rooms resting and in front area of lobby.

During today's visit, LPA Quiroz interacted with residents. The residents appeared to be clean and well taken care of. LPA Quiroz observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed to be clean and have ample soap/sanitizer. LPA Quiroz inspected residents’ bedrooms appeared to be clean with all required components. LPA Quiroz observed a check in station, COVID screening at facility entrance, hand washing stations on all floors. LPA Quiroz observed hand sanitizer throughout facility hallways on three of three floors. CONTINUED ON NEXT PAGE...

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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: 09/15/2022

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The indoor facility temperature was recorded to be between 73 degrees F- 79 degreed F. The water temperature was recorded to be between 105.2-107.2 degrees F.

LPA Quiroz observed the emergency disaster and evacuation plan. Facility has back-up emergency food and water in kitchen area and supply of PPE stored on third floor area readily available for staff and residents in care.

LPA Quiroz toured the outside of the facility and observed seating area with table and chairs for residents and visitors enjoyment in court yard area and on the third floor lounge area. Facility has completed the LIC 808 Mitigation plan, which was approved by LPA Sean Haddad on 4/28/2021 and has submitted an Infection Control Plan.

Based on the observation made during today’s visit, no deficiencies were noted during today's visit.

This report was reviewed with (AD) Cammy Johnson, and a copy of this report was provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC809 (FAS) - (06/04)

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