<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005642
Report Date: 05/30/2023
Date Signed: 05/30/2023 04:30:02 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 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
05/25/2023 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230525110514
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: 49DATE:
05/30/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Tyre Richards, Assisted Living Program Director
Carrie Galloway, Executive Director
TIME COMPLETED:
04:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not ensure that resident received prescribed medication.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of gathering additional evidence and delivering findings into the allegation listed above. LPA was greeted and granted entry by front desk staff who notified Assisted Living Program Director Tyre Richards.

An initial complaint investigation visit was conducted on May 26, 2023. A tour of the memory care unit was conducted along with a review of records for four residents among the thirteen admitted to the memory care unit at the time of the visit.

A follow-up visit including three staff interviews was conducted on May 30, 2023. Updated print-out of the Medication Administration Records were requested and provided.

CONTINUED ON FORM LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
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 2
Control Number 22-AS-20230525110514
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CROWN COVE
FACILITY NUMBER: 306005642
VISIT DATE: 05/30/2023
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
CONTINUED FROM FORM LIC9099

Regarding the allegation that Facility did not ensure that resident received prescribed medication, the following has been concluded:

The facility's nursing staff transitioned to an electronic Medication Administration Records (MAR) system in or around November 2022. Multiple resident records were reviewed for accuracy and completeness during the two visits. Absent documentation observed by LPA during the review of the records initially provided was located by facility staff Tyre Richards and notified to the Med Tech staff involved prior to the conduction of the second visit. All treatments appear to have been administered and documented. Administration information includes the shift during which a medication or treatment was dispensed along with the identity of the med staff member responsible for the act. Regularly scheduled along with random audits are conducted by the facility nurse or by the Assisted Living Program Director to ensure the accuracy of the data. Physician reports and orders appear up-to-date and current at the time of the visit.

Based on interviews conducted, records reviewed and observations conducted during a tour of the memory care unit, the allegation that Facility did not ensure that resident received prescribed medication is deemed to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute that the alleged violation did occur.

An exit interview was conducted and a copy of this report was provided to a facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2