306005642-7-15-2024-22-AS-AORZ-D7RTC4-20240802143603

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005642
Report Date: 07/15/2024
Date Signed: 07/15/2024 11:54:26 AM

Substantiated

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
11/03/2020 and conducted by Evaluator Sean Haddad

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20201103132810

FACILITY NAME:	CROWN COVE		FACILITY NUMBER:	306005642
ADMINISTRATOR:	OLSEN, KATHLEEN		FACILITY TYPE:	740
ADDRESS:	3901 EAST COAST HIGHWAY		TELEPHONE:	(949) 760-2800
CITY:	CORONA DEL MAR	STATE: CA	ZIP CODE:	92625
CAPACITY:	97	CENSUS: 68	DATE:	07/15/2024
		UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Janette Hill		TIME COMPLETED:	11:35 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not provide treatment to resident with stage 3 pressure and ankle injury
Facility did not report pressure/ankle injury to resident's responsible party
Resident denied visitation from responsible party
Facility staff missed dosages of medication

INVESTIGATION FINDINGS:

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

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPA met with Administrator (AD) Janette Hill, discussed the purpose of the inspection, and explained the allegations. The investigation into the allegations that the facility did not provide treatment to resident with stage 3 pressure and ankle injury, the facility did not report pressure/ankle injury to resident's responsible party, a resident denied visitation from responsible party, and facility staff missed dosages of medication revealed the following: During the course of the investigation, LPA interviewed former administrators, staff, and a witness, and obtained and reviewed copies of the resident roster, staff roster, Photographs of Resident #1 (R1), R1’s Home Health Medical Records dated December 29, 2020, R1’s Home Health Medical Records dated January 21, 2021, R1’s Physician’s Report dated December 27, 2019, R1’s Assessment dated December 31, 2019, R1’s Preplacement Appraisal dated January 1, 2020, R1’s Service Plan dated March 25, 2021, R1’s Assessment dated February 28, 2020, R1’s Assessment dated October 16, 2020, Provider Information Notice (PIN) 20-07-ASC, PIN 20-08-ASC

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

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 9

Control Number 22-AS-20201103132810

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: CROWN COVE	FACILITY NUMBER: 306005642
	VISIT DATE: 07/15/2024

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

R1’s Hoag Hospital Medical Records dated March 15, 2020, R1’s Primary Care Medical Records dated January 20, 2020, and Medication Administration Records for 2020.
Regarding the allegation that the facility did not provide treatment to resident with stage 3 pressure and ankle injury: it was alleged that R1 developed a stage 3 pressure injury on their left ankle at the facility and did not receive proper treatment. LPA interviewed a witness who stated that prior to entering the facility on January 1, 2020, R1 did not have a pressure injury, but on August 16, 2020, while at an urgent care for ankle swelling, an ankle bandage over R1’s left ankle was removed and R1’s stage 3 pressure injury was first discovered and R1 was referred to wound care. LPA reviewed Photographs of R1 showing the ankle bandage on August 14, 2020, the status of R1’s ankle wound on August 16, 2020, and the current status of R1’s legs and ankles. LPA reviewed R1’s Home Health Medical Records dated December 29, 2020, which corroborate that R1 had an unstageable pressure injury on their left ankle as of August 22, 2020, which had not healed by November 18, 2020, and that home health was initiated on July 27, 2020, but that the pressure injury was not originally in the care plan as of that date. LPA reviewed R1’s Home Health Medical Records dated January 21, 2021, which corroborate that R1 had an unstageable pressure injury on their left ankle as of November 25, 2020, which became a stage 3 pressure injury on January 6, 2021. When interviewed, a former administrator stated that R1 had a skin tear, facility staff were providing treatment, home health was initiated on July 26, 2020, and home health provided wound care to R1 but did not indicate the stage of the wound, and the facility reported the issue to R1’s responsible party at an unknown date. LPA reviewed R1’s Physician’s Report dated December 27, 2019, which states that R1 has a history of left ankle cellulitis. LPA reviewed R1’s Assessment dated December 31, 2019, which indicates R1 has no skin breakdown but has healing wounds and is able to completely self-manage the condition. LPA reviewed R1’s Preplacement Appraisal dated January 1, 2020, which does not mention any issues with skin or wounds. LPA interviewed a former administrator who stated that that R1 had healing wounds documented as of February 22, 2020, and the goal was improved healing of the wound. LPA reviewed R1’s Service Plan dated March 25, 2021, which states that as of February 22, 2020, R1 has healing wounds but is able to completely self-manage the condition. LPA reviewed R1’s Assessment dated February 28, 2020, which indicates R1 has no skin breakdown and no healing wounds or bedsores. LPA reviewed R1’s Assessment dated October 16, 2020, which indicates R1 requires regular staff evaluation and assistance in managing skin care needs and has a healing wound and requires staff monitoring and assistance. Based on the information obtained, R1 had a known history of skin issues but due to lack of care, oversight, and treatment, R1’s skin issues worsened and R1 developed an unstageable pressure injury while in care which eventually became a stage 3 pressure injury.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 9

Control Number 22-AS-20201103132810

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: CROWN COVE	FACILITY NUMBER: 306005642
	VISIT DATE: 07/15/2024

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

Regarding the allegation that the facility did not report pressure/ankle injury to resident's responsible party: it was alleged that the facility did not notify R1’s responsible party of R1’s stage 3 pressure injury. LPA interviewed a witness who stated that R1’s responsible party had no notice of R1’s pressure injury until it was discovered at an urgent care on August 16, 2020. When interviewed, a former administrator stated that the facility reported R1’s skin issue to R1’s responsible party at an unknown date. LPA reviewed R1’s Home Health Medical Records dated December 29, 2020, which corroborate that R1’s stage 3 pressure injury was not reported by the facility as R1’s home health plan of care and list of diagnoses did not include any pressure injuries as of July 27, 2020. Instead, R1’s unstageable pressure injury was added to R1’s home health plan of care and list of diagnoses on August 22, 2020, only after the pressure injury was discovered at an urgent care on August 16, 2020. Based on the information obtained, R1 developed an unstageable pressure injury at the facility and R1’s reporting party was not timely notified.

Regarding the allegation of resident denied visitation from responsible party: it was alleged that during the facility’s COVID-19 lockdown, R1’s responsible party was not allowed to visit R1 in person for three months. LPA interviewed a witness who stated that the facility imposed a mandatory quarantine for any resident that left the facility for any reason, regardless of symptoms or exposure, R1 went to the hospital on March 15, 2020 and returned the same day and R1’s responsible was not allowed to visit R1 on that day, on March 18, 2020, or on March 24, 2020 due to the quarantine, and R1’s responsible party was advised that if R1 went outside the facility to see them R1 would have to be quarantined for another 14 days. When interviewed, a former administrator stated that the facility was not allowing visitation, but was allowing window visits. LPA interviewed another former administrator who reported that the policy around March 15, 2020 was that residents had to isolate for 14 days after leaving the facility. LPA reviewed California Department of Social Services Provider Information Notice (PIN) 20-07-ASC, effective March 13, 2020, which states that, as prevention measures, facilities should restrict visitors, where there are COVID-19 confirmed cases in the surrounding community, and limit resident activities outside of their rooms. However, this PIN does not allow for the isolation of a resident unless the resident has a known exposure or is displaying symptoms of COVID-19. PIN 20-08-ASC, effective March 18, 2020, superseded, PIN 20-07-ASC, but does not change this guidance. LPA reviewed R1’s Hoag Hospital Medical Records dated March 15, 2020, which do not indicate R1 was exposed to or symptomatic for COVID-19. Based on the information obtained, the facility was not following the applicable PIN by requiring isolation of residents and not allowing outdoor visits.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 9

Control Number 22-AS-20201103132810

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: CROWN COVE	FACILITY NUMBER: 306005642
	VISIT DATE: 07/15/2024

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

Regarding the allegation that facility staff missed dosages of medication: it was alleged that there were multiple instances where R1’s medication times were missed. LPA interviewed a witness who stated that they observed R1 not receiving their medication on time and that the medications would be given hours late which would cause R1 to be groggy. LPA reviewed R1’s Primary Care Medical Records dated January 20, 2020, which indicate that R1’s doctor recommended R1’s Parkinson’s Disease medication be administered at 8AM, 1PM, and 6PM and that the medication will wear off after 5 hours and make R1 a higher fall risk. LPA interviewed a former administrator who was unable to provide information about this allegation. LPA reviewed R1’s Medication Administration Records for 2020 which show multiple instances of R1’s Parkinson’s Disease medication, Carbidopa-Levodopa, and other medications not being signed off by facility staff as having been given to R1 and that R1 did not receive their Trazodone and other medications for extended periods of time because the medications were not available. LPA obtained information corroborating that facility staff missed multiple doses of R1’s important medications that could have led to increased fall risk and other serious issues.

During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 9

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
11/03/2020 and conducted by Evaluator Sean Haddad

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20201103132810

FACILITY NAME:	CROWN COVE		FACILITY NUMBER:	306005642
ADMINISTRATOR:	OLSEN, KATHLEEN		FACILITY TYPE:	740
ADDRESS:	3901 EAST COAST HIGHWAY		TELEPHONE:	(949) 760-2800
CITY:	CORONA DEL MAR	STATE: CA	ZIP CODE:	92625
CAPACITY:	97	CENSUS: 68	DATE:	07/15/2024
		UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Janette Hill		TIME COMPLETED:	11:35 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not call 911
Facility staff overmedicated resident
Facility staff falsified care plan documentation
Unlawful increase in care cost

INVESTIGATION FINDINGS:

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

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

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

LIC9099 (FAS) - (06/04)

Page: 5 of 9

Control Number 22-AS-20201103132810

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: CROWN COVE	FACILITY NUMBER: 306005642
	VISIT DATE: 07/15/2024

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

Regarding the allegation that staff did not call 911: it was alleged that during an emergency, facility staff did not call 911 but instead called R1’s responsible party to request permission to call the paramedics. LPA interviewed a witness who stated that on the morning of March 15, 2020, facility staff had checked on R1 at 6:30AM and 8:00AM but could not wake R1 and should have called 911 then, but instead waited until 10:20AM to call R1’s responsible party to ask for permission to call 911 which was given. However, LPA did not obtain information corroborating that facility staff observed R1 having a medical emergency at 6:30AM or 8:00AM. LPA reviewed the facility’s Internal Incident Reports for R1 and did not find an incident report for this date. LPA interviewed a former administrator who was unable to provide information about this allegation. LPA reviewed R1’s Hoag Hospital Medical Records dated March 15, 2020, which indicate R1 made to the hospital by 11:32AM, was alert with no distress, was not diagnosed with any medical conditions, and was released the same day with no new diagnoses. LPA did not obtain information corroborating the length of delay or that R1 sustained any serious injury as a result of this incident or any delay in the facility seeking care for R1.

Regarding the allegation that facility staff overmedicated resident: it was alleged that R1 suffered a fall at the facility, went to the hospital, and the emergency room physician and R1’s physician verbally stated they thought R1 must have been overmedicated. LPA interviewed a witness who was told by the emergency room physician on March 15, 2020, that R1 was overmedicated. LPA interviewed a former administrator who was unable to provide information regarding this allegation. However, LPA reviewed R1’s Hoag Hospital Medical Records dated March 15, 2020, which do not corroborate this allegation. LPA did not obtain information corroborating this allegation.

Regarding the allegation that facility staff falsified care plan documentation: it was alleged that the facility falsified R1’s care plan documentation. LPA interviewed a witness who stated that that R1’s care plan was updated at the end of May 2020 and that while the original care plan was created by the facility’s nurse, the updates to the care plan were made by the facility’s memory care activities director. LPA interviewed a former administrator who was unable to provide information regarding this allegation. LPA reviewed a Service Change Approval Form dated May 28, 2020, which shows that the facility’s nurse approved the changes to the care plan and an interview with another former administrator revealed that the changes were made by the memory care director, not the activities director. LPA did not obtain information corroborating that R1’s care plans were falsified or created by unqualified staff.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 9

Control Number 22-AS-20201103132810

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: CROWN COVE	FACILITY NUMBER: 306005642
	VISIT DATE: 07/15/2024

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

Regarding the allegation of unlawful increase in care cost: it was alleged that on May 8, 2020, R1’s responsible party received an invoice showing an increase in level of care from tier 2 to tier 3, inquired why the level of care had increased, but was not provided any explanation as to why the level of care had increased or what new care R1 needed. LPA interviewed a witness who stated that at the end of May 2020, the facility raised R1’s level of care from tier 2 to tier 3 without a proper care plan or discussion, but that after the increase was disputed, the facility corrected the issue and began charging the new rate after a new care plan was created by a nurse. LPA reviewed a Service Change Approval Form dated May 28, 2020, which shows that the facility’s nurse approved the changes to the care plan and that these changes were discussed with R1’s responsible party. The information obtained is conflicting and LPA did not obtain information corroborating that R1’s responsible party had to pay an amount which they disputed.

Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

LIC9099 (FAS) - (06/04)

Page: 7 of 9

Control Number 22-AS-20201103132810

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: CROWN COVE	FACILITY NUMBER: 306005642
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/15/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/16/2024 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care. (a) … (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents… This requirement was not met as evidenced by	1 2 3 4 5 6 7	The licensee stated they have created a protocol for preventing pressure injuries in residents with skin issues and mobility issues and that staff have been trained on this protocol. Licensee stated they will submit the protocol and training records to LPA by POC due date.
	8 9 10 11 12 13 14	Based on documents and interviews, the licensee did not ensure R1, who had known skin issues, received proper assistance and medical care resulting in R1 developing an unstageable wound, which poses an immediate health risk to persons in care.	8 9 10 11 12 13 14
Type B 07/29/2024 Section Cited CCR 87466	1 2 3 4 5 6 7	Observation of the Resident. ... When changes … are observed, the licensee shall ensure that such changes are documented and brought to the attention of … the resident's responsible person, if any. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The licensee stated they have created a protocol for documenting skin issues and other changes of condition with residents and notifying their families and doctors and that staff are trained on these protocols. Licensee stated they will submit the protocol and training records to LPA by POC due date.
	8 9 10 11 12 13 14	Based on documents and interviews, the licensee did not ensure R1’s worsening skin condition was noted and brought to the attention of their responsible party, which poses a potential health risk to persons in care.	8 9 10 11 12 13 14

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: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

LIC9099 (FAS) - (06/04)

Page: 8 of 9

Control Number 22-AS-20201103132810

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: CROWN COVE	FACILITY NUMBER: 306005642
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/15/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/16/2024 Section Cited CCR 87468.1(a)(6)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities. (a) … (6) To leave or depart the facility at any time... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The licensee previously submitted a plan of correction on 06/12/20 that included a letter to residents and family with an updated policy that does not mandate forced quarantine and has already conducted in-service training to all staff as well.
	8 9 10 11 12 13 14	Based on documents and interviews, the licensee did not licensee did not ensure that R1 was free to leave or depart from the facility without being forced to quarantine in their room upon return, which poses an immediate personal rights risk to persons in care.	8 9 10 11 12 13 14	Licensee stated they will submit their current infection control protocols regarding isolation to LPA by POC due date.
Type A 07/16/2024 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care. (a) … (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by	1 2 3 4 5 6 7	The licensee stated they created a protocol for auditing medications, ordering medications timely, and ensuring residents receive their medications as prescribed and that staff are trained on this protocol. Licensee stated they will submit this protocol and training records to LPA by POC due date.
	8 9 10 11 12 13 14	Based on documents and interviews, the licensee did not ensure R1 received multiple medications as prescribed, which poses an immediate health risk to persons in care.	8 9 10 11 12 13 14

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: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

LIC9099 (FAS) - (06/04)

Page: 9 of 9