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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005556
Report Date:
03/25/2024
Date Signed:
03/25/2024 02:21:15 PM
Document Has Been Signed on
03/25/2024 02:21 PM
- 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:
CROWN MANOR AT PASEO GRANDE
FACILITY NUMBER:
306005556
ADMINISTRATOR:
BIM, KEVIN
FACILITY TYPE:
740
ADDRESS:
819 NORTH DELPHINE PL
TELEPHONE:
(714) 870-1198
CITY:
FULLERTON
STATE:
CA
ZIP CODE:
92833
CAPACITY:
6
CENSUS:
5
DATE:
03/25/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
08:45 AM
MET WITH:
Kevin Bim - Administrator
TIME COMPLETED:
12:50 PM
NARRATIVE
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to complete anrequired annual visit. LPA was greeted and granted entry into the facility by Caregiver Danica Mallari and explained the reason for the visit. Administrator Kevin Bim arrived shortly after.
At 8:50AM LPA Mendivil toured the facility with Caregiver Danica. At 8:55am LPA Mendivil observed unsecured pre-poured medications on kitchen counter. At 8:56 am LPA Mendivil observed unsecured PRN medications on kitchen counter. At 8:57 am LPA Mendivil observed unsecured toxins underneath kitchen sink. At 9:00am LPA Mendivil observed unsecured medications in refrigerator drawer. At 9:01 am LPA Mendivil observed unsecured sharps in kitchen drawer near kitchen stove. LPA observed required department postings throughout the facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. The facility is maintained at a comfortable temperature. LPA inspected the bathroom and LPA measured the hot water temperature which measured 108 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. Bathrooms are equipped with required safety measures such as non-skid mats and grab bars. Lighting is sufficient to ensure safety and comfort. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. The facility has an available clean supply of linens. LPA inspected residents’ bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Storage space is provided for residents in their bedroom. Smoke detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways are free of obstructions. Facility provides activities in the form of games and exercise.
LPA Mendivil reviewed 5 out of 6 residents files all except 1 contained all required documents. LPA observed 1 out of 6 residents did not have an updated LIC 602 Physician's Report.
SUPERVISOR'S NAME:
Alisa Ortiz
TELEPHONE:
(714) 703-4084
LICENSING EVALUATOR NAME:
Andrea Mendivil
TELEPHONE:
714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE:
03/25/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
7
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:
CROWN MANOR AT PASEO GRANDE
FACILITY NUMBER:
306005556
VISIT DATE:
03/25/2024
NARRATIVE
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LPA Mendivil observed 4 out of 6 residents had half bed rails without physicians' order, the remaining 2 residents are on hospice. LPA Mendivil observed facility's emergency drill has not been completed since 9/12/2023. LPA Mendivil observed fireplace that was not adequately secured. LPA did not observe emergency food and water. LPA observed in 2 out of 4 residents bedrooms contained auditory monitors which provide audio from residents rooms to kitchen, without resident consent documented.
Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.
SUPERVISOR'S NAME:
Alisa Ortiz
TELEPHONE:
(714) 703-4084
LICENSING EVALUATOR NAME:
Andrea Mendivil
TELEPHONE:
714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE:
03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/25/2024
LIC809
(FAS) - (06/04)
Page:
2
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7
Document Has Been Signed on
03/25/2024 02:21 PM
- It Cannot Be Edited
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:
CROWN MANOR AT PASEO GRANDE
FACILITY NUMBER:
306005556
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/25/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above as LPA observed unsecured medications on kitchen counter and in the refridgerator which poses an immediate health, safety risk to persons in care.
POC Due Date:
03/26/2024
Plan of Correction
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2
3
4
Administrator corrected during LPA's visit.
Type A
Section Cited
CCR
87645(h)(5)
(h) The following requirements shall apply to medications which are centrally stored:
(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as LPA observed pre-poured medications for AM and PM which poses an immediate health and safety risk to persons in care.
POC Due Date:
03/26/2024
Plan of Correction
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4
Administrator agreed to utilize Medication Administration Records and provide an inservice training to staff. Administrator to provide proof to LPA by POC due date.
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:
Alisa Ortiz
TELEPHONE:
(714) 703-4084
LICENSING EVALUATOR NAME:
Andrea Mendivil
TELEPHONE:
714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE:
03/25/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/25/2024
LIC809
(FAS) - (06/04)
Page:
3
of
7
Document Has Been Signed on
03/25/2024 02:21 PM
- It Cannot Be Edited
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:
CROWN MANOR AT PASEO GRANDE
FACILITY NUMBER:
306005556
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/25/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(c)(5)
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 6 persons which poses an immediate health and safety risk to persons in care.
POC Due Date:
03/26/2024
Plan of Correction
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Administrator agreed to have updated LIC 602 Physicians Report and provide proof to LPA Mendivil by POC due date.
Type A
Section Cited
CCR
87705(f)(1)
(f) The following shall be stored inaccessible to residents with dementia:(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as LPA observed unsecured knvies in kitchen drawer which poses an immediate health and safety to persons in care.
POC Due Date:
03/26/2024
Plan of Correction
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2
3
4
Adminstrator corrected during LPA's visit.
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:
Alisa Ortiz
TELEPHONE:
(714) 703-4084
LICENSING EVALUATOR NAME:
Andrea Mendivil
TELEPHONE:
714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE:
03/25/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/25/2024
LIC809
(FAS) - (06/04)
Page:
4
of
7
Document Has Been Signed on
03/25/2024 02:21 PM
- It Cannot Be Edited
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:
CROWN MANOR AT PASEO GRANDE
FACILITY NUMBER:
306005556
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/25/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
(f) The following shall be stored inaccessible to residents with dementia:
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as LPA Mendivil observed unsecured toxins under stove in the kitchen which poses an immediate health and safety risk to persons in care.
POC Due Date:
03/26/2024
Plan of Correction
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2
3
4
Administrator corrected during LPA's visit.
Type A
Section Cited
CCR
87608(a)(3)
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.
(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in 4 out of 6 persons as LPA observed 4 out of 6 residents did not have physician's orders for postural supports which poses an immediate health and safety or personal rights risk to persons in care.
POC Due Date:
03/26/2024
Plan of Correction
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3
4
Administrator agreed to remove postural supports until physician's orders are obtained and provide proof to LPA by POC due date.
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:
Alisa Ortiz
TELEPHONE:
(714) 703-4084
LICENSING EVALUATOR NAME:
Andrea Mendivil
TELEPHONE:
714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE:
03/25/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/25/2024
LIC809
(FAS) - (06/04)
Page:
5
of
7
Document Has Been Signed on
03/25/2024 02:21 PM
- It Cannot Be Edited
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:
CROWN MANOR AT PASEO GRANDE
FACILITY NUMBER:
306005556
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/25/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.269(2)
(2) To be granted a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above as LPA observed audio monitors in 2 out of 5 residents bedrooms without resident consent which poses a potential personal rights risk to persons in care.
POC Due Date:
04/01/2024
Plan of Correction
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2
3
4
Adminstrator agreed to remove auditory monitors until resident/responsible party consent is obtained and recorded on file. Administrator to provide proof to LPA by POC due date.
Type B
Section Cited
HSC
1569.695(a)
(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview with Administrator Kevin Bim, the licensee did not comply with the section cited above as Administrator stated they did not have emergency food or water supplies which poses a potential health and safety risk to persons in care.
POC Due Date:
04/01/2024
Plan of Correction
1
2
3
4
Administrator to purchase emergency food and water and provide proof to LPA by POC due date.
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:
Alisa Ortiz
TELEPHONE:
(714) 703-4084
LICENSING EVALUATOR NAME:
Andrea Mendivil
TELEPHONE:
714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE:
03/25/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/25/2024
LIC809
(FAS) - (06/04)
Page:
6
of
7
Document Has Been Signed on
03/25/2024 02:21 PM
- It Cannot Be Edited
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:
CROWN MANOR AT PASEO GRANDE
FACILITY NUMBER:
306005556
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/25/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as the last documented drill was conducted on 09/12/2023 which poses a potential safety risk to persons in care.
POC Due Date:
04/01/2024
Plan of Correction
1
2
3
4
Administrator agreed to conduct an emergency drill and provide proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Alisa Ortiz
TELEPHONE:
(714) 703-4084
LICENSING EVALUATOR NAME:
Andrea Mendivil
TELEPHONE:
714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE:
03/25/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/25/2024
LIC809
(FAS) - (06/04)
Page:
7
of
7