306005316-2-7-2023-22-AS-SSAS-CP5VRS-20230217154021

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005316
Report Date: 02/07/2023
Date Signed: 02/07/2023 04:24:26 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/06/2023 and conducted by Evaluator Patricia Velazquez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230206091754

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: 138	DATE:	02/07/2023
		UNANNOUNCED	TIME BEGAN:	01:41 PM
MET WITH:	Cammy Johnson - Administrator		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Facility is in disrepair

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced initial complaint visit to initiate an investigation into the above allegation and to deliver the findings of the investigation. LPA Velazquez was allowed entry into the facility and met with Administrator Cammy Johnson and explained the purpose of the visit.

On today's visit LPA Velazquez conducted interviews with residents and staff. LPA Velazquez also requested copies of facility and resident documents. At 2:19 PM LPA Velazquez along with Administrator Johnson used the elevator to access the second and third floors and observed the elevator to be in operating condition. Regarding the allegation Facility is in disrepair during the course of the investigation the following was revealed: LPA Velazquez conducted interviews with residents and staff. LPA Velazquez also reviewed facility and resident records. The records reviewed included the facility's Emergency Disaster Plan as it relates to evacuation procedures, Fire Drill Reports, Evacuation Drill Reports for 2022 which documented staff trained in

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230206091754

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/07/2023

NARRATIVE

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these drills, an Upgrade Order Agreement dated February 2, 2023 documenting the repair of the elevator, and Avendra Elevator/Escalator Maintenance Property Level Agreement documenting the monthly elevator maintenance services. Other records reviewed included resident Physician's Reports and Identification and Emergency Information. Seven of seven individuals interviewed confirmed the elevator was out of service for some days. Per Administrator Johnson the elevator was repaired and back in operation on February 6, 2023.

Based on LPA's observations, interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Facility is in disrepair is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D.

An exit interview was conducted with Administrator Cammy Johnson and a copy of this report along with the appeal rights were provided at the time of this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230206091754

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/07/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include...and procedures for the safety and well-being of residents, employees and visitors.	1 2 3 4 5 6 7	The elevator was repaired and the citation was corrected at the time of this visit. Correction letter was provided at the time of this visit.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: based on observation, record review & interview the licensee did not ensure the elevator was maintained in operating condition. This poses a potential risk to the health & safety of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC9099 (FAS) - (06/04)

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