306005556-2-20-2025-22-AS-BLOZ-DE3S28-20250220122907

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005556
Report Date: 02/20/2025
Date Signed: 02/20/2025 12:31:31 PM

Document Has Been Signed on 02/20/2025 12:31 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	CROWN MANOR AT PASEO GRANDE		FACILITY NUMBER:	306005556
ADMINISTRATOR/ DIRECTOR:	BIM, KEVIN		FACILITY TYPE:	740
ADDRESS:	819 NORTH DELPHINE PL		TELEPHONE:	(714) 870-1198
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92833
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	02/20/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:08 AM
MET WITH:	Administrator Kevin Bim		TIME VISIT/ INSPECTION COMPLETED:	12:35 PM

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	Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit for the purpose of conducting the required annual inspection. LPA was greeted and granted entry by care giving staff after explaining the purpose for the visit. Administrator (AD) Kevin Bim was notified via telephone and later arrived to assist with the inspection. LPA observed that Administrator Kevin Bim has a valid Administrator certificate which expires on June 8, 2025. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents, of which one may be bedridden, and has a hospice waiver for three. The facility is a single story home with four resident bedrooms, of which two are shared, one staff room, one shared resident bathroom, a living room, a dining room, a kitchen, a game room, and an unattached two car garage. LPA, accompanied by the AD conducted a tour of the interior portion of the facility. On today's visit, LPA observed six residents in care and two care giving staff present. LPA observed the resident relaxing in their respective bedrooms and in the common areas. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall in the resident hallway. LPA inspected all four resident bedrooms and they were observed to be free of any hazards. LPA observed the resident bedrooms had all the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds had clean linens and blankets. LPA observed additional linens are stored in a hallway cabinet. LPA inspected the one shared resident bathroom. The resident bathroom is clean. Resident bathroom was equipped with grab bars and a nonskid floor mat. The faucet and toilet was operational. Hot water temperature measured 107.4 degrees Fahrenheit. LPA observed the staff room to be free of hazards. LPA observed that the kitchen has a two day perishable and a seven day nonperishable food supply on hand. The kitchen is clean and appliances were operational. LPA observed kitchen knives and sharps to be stored in a locked kitchen cabinet. LPA observed toxins and chemicals to be stored in a locked kitchen cabinet under the sink. CONTINUED ON LIC809-C

Sheila Santos	TELEPHONE: (714) 703-2857
Brandon Lopez	TELEPHONE: (714) 483-4521
	DATE: 02/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CROWN MANOR AT PASEO GRANDE	FACILITY NUMBER: 306005556
	VISIT DATE: 02/20/2025

NARRATIVE

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A fire extinguisher is located in the kitchen and it was observed to be charged and up to date on service. LPA tested the smoke detectors and carbon monoxide detectors which tested operational. LPA observed the facility conducted their last emergency disaster drill on September 17, 2024. The centrally stored medication is kept in a locked cabinet in the resident hallway. LPA observed a First Aid Kit to be stored in the locked cabinet and it was observed to have all the required components. LPA observed a fireplace in the living room and it was observed to be adequately fenced and not in operation at time of visit.

LPA, accompanied by the AD conducted a tour of the exterior portion of the facility. LPA observed the exterior portion of the facility to be free of obstructions and hazards. LPA observed the unattached two car garage is kept locked and inaccessible to residents in care. LPA observed the garage to be used for storage. LPA observed the facility has a three day emergency food and water supply stored in the garage. LPA observed a shaded outdoor seating area with furniture for resident use. The perimeter gate on the north side and south side of the facility are self-latching and can be open in an evacuation. There are no bodies of water on the premises.

LPA reviewed all six resident files. LPA observed that the Reappraisals for Resident #1 (R1), Resident #5 (R5), and Resident #6 (R6) were outdated. LPA observed that the facility did not have a Reappraisal on file for Resident #3 (R3). LPA reviewed all six residents' medication and medication records. LPA observed that Resident #3 (R3), Resident #5 (R5), and Resident #6 (R6) were being provided medication without the proper Physician's order. LPA reviewed four staff files. All staff are background cleared and associated to the facility.

Based on the observations made during today's visit, deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Kevin Bim. A copy of the report and Appeal Rights were provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Brandon Lopez	TELEPHONE: (714) 483-4521
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/20/2025 12:31 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
ORANGE COUNTY RO, 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: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87465(e)

Incidental Medical and Dental Care Services

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. 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 in which poses an immediate health, safety or personal rights risk to persons in care. During residents' medication and medication record review, LPA observed that Resident #3 (R3), Resident #5 (R5), and Resident #6 (R6) were being provided medication without a proper Physician's order.
	POC Due Date: 02/21/2025
	Plan of Correction
1 2 3 4	AD agreed to destroy the medications without a Physician's order for Resident #3 (R3) , Resident #5 (R5), and Resident #6 (R6). LPA observed AD seperate the medications and prepare them for destruction at time of visit. POC cleared during visit.

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.

Sheila Santos	TELEPHONE: (714) 703-2857
Brandon Lopez	TELEPHONE: (714) 483-4521
	DATE: 02/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/20/2025 12:31 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
ORANGE COUNTY RO, 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: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87463(a)

Reappraisals

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. 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 in which poses/posed a potential health, safety or personal rights risk to persons in care. During resident file review, LPA observed that the Reappraisals for Resident #1 (R1), Resident #5 (R5), and Resident #6 (R6) were outdated. LPA also observed that there was not a Reappraisal on file for Resident #3 (R3).
	POC Due Date: 03/06/2025
	Plan of Correction
1 2 3 4	AD agreed to get new Reappraisals for Resident #1 (R1), Resident #3 (R3), Resident #5 (R5), and Resident #6 (R6). AD agreed to submit the Reappraisals to LPA via email or fax by POC date.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(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 in which poses/posed a potential health, safety or personal rights risk to persons in care. During the facility file review, LPA observed that the facility conducted their last emergency disaster drill on 09/17/2024. The facility did not conduct an emergency disaster drill for the last quarter of 2024.
	POC Due Date: 03/06/2025
	Plan of Correction
1 2 3 4	AD agreed to conduct an emergency disaster drill and submit proof of completion to LPA via email or fax by POC 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.

Sheila Santos	TELEPHONE: (714) 703-2857
Brandon Lopez	TELEPHONE: (714) 483-4521
	DATE: 02/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

LIC809 (FAS) - (06/04)

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