306005642-1-27-2025-22-AS-AORZ-DDEMQW-20250130084925

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005642
Report Date: 01/27/2025
Date Signed: 01/27/2025 03:08:13 PM

Unsubstantiated

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
12/20/2021 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20211220140822

FACILITY NAME:	CROWN COVE		FACILITY NUMBER:	306005642
ADMINISTRATOR:	KAMESHI TAYLOR		FACILITY TYPE:	740
ADDRESS:	3901 EAST COAST HIGHWAY		TELEPHONE:	(949) 760-2800
CITY:	CORONA DEL MAR	STATE: CA	ZIP CODE:	92625
CAPACITY:	97	CENSUS: 59	DATE:	01/27/2025
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Janette Hill		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff is authorizing medical decisions without proper consent
Resident sustained an injury from a fall while in care
Staff did not seek timely medical attention for a resident
Staff did not provide adequate supervision to a resident

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced complaint visit to continue the investigation into the above allegations. LPAs were greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPAs toured the facility and interviewed staff and residents as well as reviewed and obtained pertinent documentation such as care plans.
Regarding the allegations that staff is authorizing medical decisions without proper consent, resident sustained an injury from a fall while in care, staff did not seek timely medical attention for a resident and staff did not provide adequate supervision to a resident, the investigation revealed the following: Per facility care plan dated 01/29/2021, Resident 1 (R1) requires assistance with showers and clothing but is independent with toileting, eating, grooming and medications. Resident does not require assurance checks and is able to leave the facility unassisted. Facility staff indicate notifying resident responsible parties when vaccinations are available however no signatures were required if resident was able to make their own decisions. CONTINUED ON LIC 9099C DATED 01/27/2024

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	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.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20211220140822

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: 01/27/2025

NARRATIVE

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Facility documentation indicated resident signed on own for flu vaccine and indicated receiving the Pfizer covid vaccine. There is no documentation of a durable power of attorney (DPOA) at the facility for R1 and document checklist does not show that a DPOA was received by the facility. Interview with Administrator at time of complaint denied knowledge of any falls. Facility does not have documentation of any falls and care plan states no history of falls. Facility does not have any documentation of hospitalization for a fall for the resident. Facility staffing levels are as follows: Three caregivers in Assisted Living and Memory Care and 2 med techs for 1st and 2nd shift and 1 caregiver and med tech for NOC shift. Three out of three staff and five out of five residents state current staffing levels are good and resident needs are being met. Interview with former Administrator indicated struggling with staffing during the pandemic and using agency to fill holes. Facility Administrator denies facility advertises having an RN on-site and state the facility employs an LVN only. Current facility website does not advertise any nursing staff. Due to the age of the complaint, facility is unable to provide all documents and/ or records requested by the department. Based on interviews conducted and record review, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed to be Unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violations did occur.

An exit interview was conducted and a copy of this report was provided to a facility representative.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	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

LIC9099 (FAS) - (06/04)

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