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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005642
Report Date: 10/30/2023
Date Signed: 10/30/2023 11:25:23 AM


Document Has Been Signed on 10/30/2023 11:25 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: 66DATE:
10/30/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Carrie GallowayTIME COMPLETED:
11:40 AM
NARRATIVE
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This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of a health and safety check and to follow up on a self-reported incident report received in the Orange County Regional Office (OCRO) on 10/25/23 regarding Resident #1 (R1). LPA met with Administrator (AD) Carrie Galloway and discussed the purpose of the inspection.

The incident report states the following: On 10/20/23, R1 left the facility to go on a walk, walked for about a mile, sat down on a bench, was offered a ride and returned to the facility by a local member of the community, and sustained no injuries.

During today’s inspection, LPA conducted a health and safety check on R1 and observed no health and safety issues. LPA observed the facility to be clean and organized and found no health and safety issues. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food, the electricity and water were running, the facility had soap and paper towels, and the medications and sharps were properly stored. LPA confirmed placement of door alarms in the memory care unit. LPA interviewed AD and requested and reviewed copies of the resident roster, staff roster, and R1’s resident file.

The investigation into the incident revealed the following: Per R1’s Physician’s Report dated 06/16/23, R1 does not have dementia but is not able to leave the facility unassisted. Per AD, at the time of the incident, R1 resided in the assisted living section of the facility. However, after the incident, R1 obtained a new Physician’s Report dated 10/26/23 which states R1 does have dementia and is not able to leave the facility unassisted. R1 now resides in the memory care unit.

CONTINUED.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
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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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
VISIT DATE: 10/30/2023
NARRATIVE
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Per AD, R1 left the facility through the front door stating they were going for a walk and this was not unusual because R1 is part of a walking club. After the incident, the facility added motion alarms on the front entryway, created an updated list of residents who are unable to leave the facility unassisted for staff to be aware, and conducted training for front door staff on residents leaving without assistance. LPA confirmed all these items during the inspection.

Based on the information obtained during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/30/2023 11:25 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: 10/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2023
Section Cited
CCR
87464(f)(1)

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87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision... This requirement was not met as evidenced by:
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Licensee added motion alarms to the front entryway, created an updated list of residents unable to leave unassisted, and conducted training for staff. LPA confirmed these items during the inspection. POC CLEARED.
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Based on interview and documents, the licensee did not provide adequate supervision to R1 when R1 left the facility without assistance, which posed an immediate safety risk to persons 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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
LIC809 (FAS) - (06/04)
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