306005316-1-30-2024-22-AS-MVAO-CZZ2CU-20240130161718

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005316
Report Date: 12/28/2023
Date Signed: 01/30/2024 10:01:21 AM

Unsubstantiated

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
09/21/2023 and conducted by Evaluator Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230921121149

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: 148	DATE:	12/28/2023
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Cammy Johnson-Administrator		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff mismanaged resident's medication.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of continuing the investigation and delivering the findings into the above allegation. LPA explained the reason for the visit and reviewed the allegation with Administrator (Admin) Cammy Johnson.

On September 28, 2023, LPA Cho initiated the complaint investigation received on September 21, 2023. During the course of the investigation, LPA interviewed staff and obtained documentation pertaining to Resident #1 (R1). The following was determined:

It is alleged that the staff mismanaged the resident’s medication. R1 was admitted to the facility on December 23, 2022. R1 was independent and was able to manage their own prescription medications per the Physician’s Report dated December 13, 2022. Although the resident was able to self-administer their own medications per the physician’s assessment, R1's medication was managed by the facility. On January 19, 2023, the medication was given to R1 for self-management.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

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

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 22-AS-20230921121149

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: 12/28/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on the LPA's review of the Medication Administration Record (MAR), medications were administered properly between December 24, 2022 to January 29, 2023.

Per interviews conducted, four out of the four staff indicated that the medications were administered as prescribed at the time when R1’s medications were managed including the pain medication. Based on observations, there were no sufficient evidence to support the allegation.

Therefore, based on the interviews which were conducted and the records that were reviewed, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the following allegation: Staff mismanaged resident’s medication is deemed UNSUBSTANTIATED.

An exit interview was conducted with Administrator Cammy Johnson, and a copy of this report including the LIC811 were provided at the end of the visit.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2