306006017-3-1-2023-22-AS-RMAZ-CPHS49-20230301123223

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006017
Report Date: 03/01/2023
Date Signed: 03/01/2023 12:32:34 PM

Document Has Been Signed on 03/01/2023 12:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	CRESCENT LANDING AT FULLERTON MEMORY CARE		FACILITY NUMBER:	306006017
ADMINISTRATOR:	MCCASKILL, SHERYL YVETTE		FACILITY TYPE:	740
ADDRESS:	1510 E. COMMONWEALTH AVENUE		TELEPHONE:	(419) 247-2800
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92831
CAPACITY:	72	CENSUS: 26	DATE:	03/01/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Patty Rager, Executive Director		TIME COMPLETED:	12:45 PM

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	Licensing Program Analyst (LPA) Ruth Martinez conducted an announced visit to the facility for purpose of a pre-licensing evaluation. An initial application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (72) capacity, (47) ambulatory, (25) non-ambulatory, and (0) bedridden resident was submitted to CCL on 05/18/21. Structure: The facility has a main building that is two stories and an additional one story building with buildings adjacent to each other with 30 resident bedrooms, 10 full bathrooms, 1 theater room, a restaurant style kitchen, 1 dining room, 1 rehab clinic, 1 kitchenet, private dining room and visitor center. The resident’s bedrooms are spacious and will easily accommodate the resident’s furnishings. There is a large courtyard with 1 exit walkway with covered seating for the residents and seating throughout the courtyard. Facility main building is two stories and only used for administrative purposes. Signal system: Facility has a monitored delayed egress in place. Air/Heating: Central air/heating system installed with a central panel to control entire facility. Continued on LIC809-C

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023

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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CRESCENT LANDING AT FULLERTON MEMORY CARE	FACILITY NUMBER: 306006017
	VISIT DATE: 03/01/2023

NARRATIVE

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Bedrooms Residents:
Bedrooms will accommodate residents with either a private bedroom or shared bedroom.

Bedrooms Staff:
No bedroom designated for awake-staff.

Bathrooms:
All bathrooms have a working toilet, wash basin, walk in shower. Resident bedrooms have a half bathroom.
Linens & Hygiene Supplies:
Adequate supply of linen stored in storage space.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one week prior and listed for food serve for one week.

Food Service:
Adequate supply of 7-day non-perishable and 2-day perishables are stored in the kitchen with surplus goods stored in designated kitchen storage unit.

Smoke Detectors:
Smoke detectors and carbon monoxide alert systems are hardwired. Inspections are done by a vendor quarterly. The facility has monitored alarm system, sprinklers and delayed egress.

Appliances:
Facility main kitchen is equipped with ovens/ranges/microwaves, prep counters, refrigeration, freezer, grill, steam tables, and ice makers. The facility has 2 laundry units with washers and dryers.

Continued on LIC809-C

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023

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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CRESCENT LANDING AT FULLERTON MEMORY CARE	FACILITY NUMBER: 306006017
	VISIT DATE: 03/01/2023

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Toxins:
All and any toxic chemicals, cleaning solutions and disinfectants are inaccessible to residents are stored and locked in storage.

Water Temperature:
Tested and recorded maintained at a comfortable temperature and the water temperature measures 109.5 – 120.0 Fahrenheit degrees in resident restrooms and common bathrooms.

Medications, First-Aid Kit & Book:

Medication is stored in med room and First Aid kit stored in first aid cart.

Resident & Staff Files:
Records will be kept locked in the office in the administrative portion of facility.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the client's use, commensurate with the plan of operation.

Fire clearance:
Was approved on 08/04/2021.

Component III:
Component three waived during visit. Applicant is Licensee/Administrator of other licensed facilities.

Facility appears to be ready for licensure. Accordingly, LPA will submit file for approval to CCL Supervisor.
Exit interview was conducted and a copy of this report was left with the applicant.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023

LIC809 (FAS) - (06/04)

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