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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005642
Report Date: 04/28/2022
Date Signed: 04/28/2022 09:56:37 AM


Document Has Been Signed on 04/28/2022 09:56 AM - 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 COVEFACILITY NUMBER:
306005642
ADMINISTRATOR:KAMESHI TAYLORFACILITY TYPE:
740
ADDRESS:3901 EAST COAST HIGHWAYTELEPHONE:
(949) 760-2800
CITY:CORONA DEL MARSTATE: CAZIP CODE:
92625
CAPACITY:97CENSUS: 31DATE:
04/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Kameshi Taylor - Executive Director TIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced case management visit to follow up on an incident report dated 04/20/2022. LPA was greeted and granted entry into the facility and explained the reason for the visit to Kameshi Taylor, Executive Director.

Incident report indicated Resident 1 (R1) went to Hoag Hospital due to low blood pressure and edema to lower extremities on 04/05/2022. R1 remained in hospital care until passing on 04/13/2022.

Per interview with Bernadette Sajia, Assisted Living Program Director (LVN) R1 home health nurse was visiting and noticed blood pressure was low and a low grade fever. Home health nurse recommended transferring R1 to hospital and 911 was called.


During the visit, LPA reviewed LIC 602, LIC 601 and needs and services plan.



No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
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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