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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005642
Report Date: 10/18/2023
Date Signed: 10/18/2023 11:50:06 AM

Unfounded


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
06/09/2023 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20230609081714
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: 63DATE:
10/18/2023
UNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Carrie GallowayTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Licensee does not have a facility emergency disaster plan
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA interviewed staff and reviewed and obtained pertinent documentation such as emergency disaster plan. Regarding the allegation that licensee does not have a facility emergency disaster plan, the investigation revealed the following: LPA observed and reviewed the facility emergency disaster plan outlining all required emergency directives. Therefore the allegation is deemed UNFOUNDED, meaning the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was provided to facility representative.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
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 5
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
06/09/2023 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20230609081714

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: 63DATE:
10/18/2023
UNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Carrie GallowayTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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9
Residents sustained pressure injuries while in care due to neglect
Staff do not meet residents' dietary needs
Facility lacks appropriate staffing resulting in unmet residents needs
Resident sustained bruises while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA interviewed staff, witnesses, and residents as well as reviewed and obtained pertinent documentation such as hospice notes. Regarding the allegations that residents sustained pressure injuries while in care due to neglect, staff do not meet residents' dietary needs, facility lacks appropriate staffing resulting in unmet residents needs and resident sustained bruises while in care, the investigation revealed the following: Resident 1 (R1) has documented blisters on buttocks and redness on coccyx that Hospice was monitoring. Hospice provided teaching to staff on keeping the wound dry and turning the resident every two hours. Staff indicated repositioning R1 per Hospice instructions. Interview with Hospice indicates unsure if neglect was occurring regarding the resident's pressure injuries. Incontinence care was esential to the management of R1's wounds. Hospice indicates resident being found soiled on various occasions. CONTINUED ON LIC 9099C DATED 10/18/2023
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20230609081714
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: 10/18/2023
NARRATIVE
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Eight out of ten staff/ witnesses deny a lack of incontinence care for any residents. Six out of six staff/ witnesses deny either observing bruises on R1 or indicated a bruise was from the integrity of the resident's skin due to the resident's condition and deny abuse. LPA observed residents dining at lunch time in the common area of the memory care unit. All staff interviewed indicated residents are brought out of their rooms for meals and witnesses corroborate this. Memory care unit averages a census of 13-14 residents daily. Facility schedule indicates staffing as follows: 2-3 caregivers/ 2 med techs/ Resident Services Director on first shift, and 2 caregivers/ 1 med tech on second shift and NOC shift. Facility has a full time nurse as well. Five out of eight staff/ witnesses indicate facility has suffered with staffing shortages but staffing levels appear better now. Three out of eight staff/ witnesses state there were not always two people available for a two person assist for R1. Due to conflicting information, LPA is unable to corroborate the allegations. Based on interviews conducted and observation during a tour of the memory care unit, 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 OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
06/09/2023 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20230609081714

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: 63DATE:
10/18/2023
UNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Carrie GallowayTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff lacks required training
INVESTIGATION FINDINGS:
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2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as training records. During the investigation, LPA requested training records for seven staff. Seven out of seven staff members do not have evidence of required annual training. LPA observed fire drill training dated 02/06/2023 and 03/31/2023.
Based on record review and interviews conducted,The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to facility administrator along with appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20230609081714
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: 10/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2023
Section Cited
CCR
87412(c)
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Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not being met as evidenced by:
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Licensee to conduct training for all staff on schedule and forward proof to LPA by POC due date.
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Based on record review and interviews conducted, Licensee failed to ensure staff training verification is maintained in personnel records. This poses a potential health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5