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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005642
Report Date: 01/27/2025
Date Signed: 01/28/2025 07:54:02 AM

Document Has Been Signed on 01/28/2025 07:54 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/
DIRECTOR:		JANETTE HILLFACILITY TYPE:
740
ADDRESS:3901 EAST COAST HIGHWAYTELEPHONE:
(760) 547-2863
CITY:CORONA DEL MARSTATE: CAZIP CODE:
92625
CAPACITY: 97TOTAL ENROLLED CHILDREN: 0CENSUS: 59DATE:
01/27/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Janette Hill - Executive Director TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On this day, Licensing Program Analysts (LPAs) Andrea Mendivil and Kimberly Lyman made an unannounced visit in conjuction with a complaint investigation for complaint control # 22-AS-20231117101241. LPAs were greeted and granted entry into the facility by Gerrardo Garibay and explained the reason for the visit. Executive Director Janette Hill arrived shortly after.

During the course of investigation LPA Mendivil requested a copy of either electronic/written Medication Administration Record for October 2023 to November 2023. Per conversation with Executive Director Janette Hill stated they were unable to locate the Medication Administration Records from 2023.

Based on observations a deficiency is being cited per California Code of Regulations Title 22. An exit interview was conducted and a copy of this report was provided.
Alisa OrtizTELEPHONE: (714) 703-4084
Andrea MendivilTELEPHONE: 714-703-2738
DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025
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 2
Document Has Been Signed on 01/28/2025 07:54 AM - 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 COVE
FACILITY NUMBER: 306005642

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87506(e)
(e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement was not met as evidence by facility did not obtain Medication Administration Records from 2023.
Deficient Practice Statement
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POC Due Date: 02/02/2025
Plan of Correction
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Executive Director agreed to file all records in one central location and will conduct in services. Executive Director will provide proof by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Alisa OrtizTELEPHONE: (714) 703-4084
Andrea MendivilTELEPHONE: 714-703-2738

DATE: 01/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2025

LIC809 (FAS) - (06/04)
Page: 2 of 2