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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005316
Report Date: 10/13/2025
Date Signed: 10/13/2025 01:50:08 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
11/07/2023 and conducted by Evaluator Celine Rodriguez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20231107165640
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: 132DATE:
10/13/2025
UNANNOUNCEDTIME BEGAN:
11:53 AM
MET WITH:Administrator- Gerardo "Jerry" RodriguezTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Resident sustained multiple unexplained fractures while in care.
Resident sustained an unexplained laceration while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Celine Rodrguez conducted an unannounced visit to the facility to deliver the amended findings report. LPA Rodriguez explained the purpose of today's visit and was greeted by Administrator (AD) Gerardo "Jerry" Rodriguez.

It was alleged that resident sustained multiple unexplained fractures while in care & resident sustained an unexplained laceration while in care. The investigation determined as follows:

Per documentation review, of resident 1 (R1) physician report dated for August 31, 2017, R1 had mild cognitive impairment, needed continued wound care, and secondary diagnoses was generalized weakness. It was also indicated that R1 was ambulatory, unable to independently transfer to and from bed, and was placed on fall precautions, despite R1 not having a history of falls. Three out of three staff interviews did not corroborate with the allegation by denying that R1 sustained a fracture.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Celine Rodriguez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2025
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 3
Control Number 22-AS-20231107165640
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/13/2025
NARRATIVE
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Per incident report Community Care Licensing received on November 13, 2023, incident dated for November 3, 2023, facility staff observed R1 on the floor “around 5:00 AM” and reported that R1 denied of pain, however 9-1-1 was contacted due to R1 being observed with a bump on their head.

R1 was transferred to UCI Medical hospital the same day. Per hospital discharge summary dated for November 6, 2023, R1 had “dementia” and was “nonverbal at baseline in a fetal position found down…next to bed with head bleeding for an unknown amount of time with laceration…and not following commands”. R1 was admitted to UCI hospital on November 3, 2023, and discharged on November 6, 2023. R1’s principal diagnosis was “mechanical GLF c/b C1-C2 fracture, right femur”. According to the hospital physician, R1 was not a surgical candidate due to R1 having “poor functional status”. Per UCI discharge summary, R1 sustained a hangman’s fracture, multiple compression fractures, and intertrochanteric femur fracture. R1 was placed on “home with home hospice” upon discharge from the hospital and was receiving continued wound care from November 3, 2023 to November 30, 2023. In December 2023, R1 passed away in the middle of the night.

Based on the information gathered during the investigation and review of documents obtained the preponderance of evidence standard has been met, therefore the allegations are determined to be SUBSTANTIATED.

The following is being cited and the Immediate Civil Penalty has been assessed and issued per California Code of Regulations, Title 22 Division 6 Chapter 8, per H&S Code Section 1569.49(f).

An exit interview was conducted with AD Rodriguez.

A copy of this report was explained, and appeal rights were provided during the visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Celine Rodriguez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20231107165640
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/14/2025
Section Cited
CCR
87466
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87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs…the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
This requirement is not met as evidence by:
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As a plan of correction (POC) facility will conduct an in-service training to all staff regarding the regulation cited. In addition, facility will also formulate a plan for residents who are a fall risk and will submit plan to assigned LPA on or by 10/14/2025.
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Based on the reviewed documents obtained and interviews conducted during the investigation, the facility failed to ensure that the resident was regularly checked and did not adhere to the fall precautions as stated in R1’s physician report, therefore sustaining a fracture during fall.
This poses an immediate health and safety risk for residents in care.

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Type A
10/13/2025
Section Cited
CCR
87464(f)(1)
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87464(f)(1) Basic Services
(f) Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement is not met as evidence by:
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As a plan of correction (POC) facility will conduct an in-service training to all staff regarding the regulation cited on or by 10/14/2025.
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Based on the reviewed documents obtained and interviews conducted during the investigation, the facility failed to ensure that R1 was provided care and supervision with the fall precautions that were implemented by R1’s physician. This resulted in R1 sustaining a laceration to the head during R1’s fall.
This poses an immediate health and safety risk for residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Celine Rodriguez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2025
LIC9099 (FAS) - (06/04)
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