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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005642
Report Date: 09/15/2022
Date Signed: 09/15/2022 11:28:15 AM


Document Has Been Signed on 09/15/2022 11:28 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:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Tonantzin Martinez- Memory Care Program Director and Tyre Richards- Assisted Living Program Director TIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Memory Care Program Director Tonantzin Martinez and explained the reason for the visit.

At 9:45 AM, LPA toured the facility with Assisted Living Program Director Tyre Richards. Facility has a capacity of 97 and currently has 31 residents in Assisted Living and Memory Care. LPA observed a screening and sanitizing station at entrance of the facility. LPA observed residents relaxing in their respective rooms and participating in activities. Facility contains the following : library, salon, activity area and garden. Facility appears clean and sanitary. All resident rooms had required elements, including bed, chair, closet space and ample lighting. Restrooms are stocked with soap and paper towels and have hand washing postings. Facility has 7 day non perishables and 2 day perishables. Facility has a secured location for resident medication and files. LPA toured the outside grounds and observed outside visitation area. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. LPA observed a 4 weeks supply of PPE. LPA reviewed residents’ files and all contained required documentation including updated emergency information.

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: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
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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