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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006017
Report Date: 07/26/2024
Date Signed: 07/26/2024 02:32:06 PM

Document Has Been Signed on 07/26/2024 02:32 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CRESCENT LANDING AT FULLERTON MEMORY CAREFACILITY NUMBER:
306006017
ADMINISTRATOR/
DIRECTOR:		DEAN, COURTNEYFACILITY TYPE:
740
ADDRESS:1510 E. COMMONWEALTH AVENUETELEPHONE:
(419) 247-2800
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY: 72CENSUS: 35DATE:
07/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Jackie Escamilla, Jesus SotoTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with facility staff Jackie Escamilla and discussed the purpose of the inspection. Administrator (AD) Jesus Soto arrived during the inspection.

LPA reviewed Infection Control requirements. At about 9:30AM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and medication room and observed the following: Structure: this is a large commercial facility. Facility is composed of two buildings. The two-story administrative building does not contain any resident rooms but contains staff offices, common areas, and storage areas. The larger one-story residential building contains 36 resident bedrooms, 29 bathrooms, common areas, medication room, dining room, kitchen, and laundry rooms. There is a large patio with patio covers for the residents. Resident Bedrooms: the 20 resident bedrooms inspected are spacious and will easily accommodate the residents’ furnishings. Furniture for 20 resident bedrooms inspected. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 115 degrees F and 119 degrees in the 4 resident bathrooms inspected. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the storage rooms. Medication room: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. The facility’s licensing fees have not been paid. At about 10:30AM, LPA reviewed 5 resident files and 5 staff files, interviewed 5 residents and 5 staff, and inspected medications for 5 residents. Facility does not handle resident money.

CONTINUED
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2024
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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Document Has Been Signed on 07/26/2024 02:32 PM - It Cannot Be Edited


Created By: Sean Haddad On 07/26/2024 at 02:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CRESCENT LANDING AT FULLERTON MEMORY CARE
FACILITY NUMBER: 306006017

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(b)
Limitations -Capacity and Ambulatory Status
(b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on documents and admission, the facility has 35 residents all of whom have dementia and are non-ambulatory but only has a non-ambulatory fire clearance for 25, which poses an immediate safety risk to persons in care. CIVIL PENALTY ASSESSED.
POC Due Date: 07/27/2024
Plan of Correction
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Licensee stated they will submit a fire clearance request to increase their non-ambulatory fire clearance to at least 35 by POC due date.
Type A
Section Cited
HSC
1569.17(c)(1)(A)
Licensing
(c)(1)(A) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in a facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on documents and the Licensing Information System, facility staff Jesenia D Vargas-Sandoval is not background cleared and has been working at the facility since May 28, 2024 per their staff file, which poses an immediate safety risk to persons in care. CIVIL PENALTY ASSESSED.
POC Due Date: 07/27/2024
Plan of Correction
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During the inspection, the licensee removed this staff from the facility and stated they will complete the background clearance process and make sure this staff does not return to the facility until they are background cleared.
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 Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 07/26/2024 02:32 PM - It Cannot Be Edited


Created By: Sean Haddad On 07/26/2024 at 02:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CRESCENT LANDING AT FULLERTON MEMORY CARE
FACILITY NUMBER: 306006017

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(b)
Other Provisions
(b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and documents, the current administrator started in 2023 but still has not been properly designated, which poses a potential safety risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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Licensee stated they will submit the LIC308, corporate board minutes, administrator's certificate, driver's license, and resume of the administrator to LPA by POC due date.
Type B
Section Cited
HSC
1569.695(f)(1)
Other Provisions
(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell, on or before July 1, 2019.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the administrative building where staff work on both floors does not have an evacuation chair, which poses a potential safety risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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Licensee stated they will purchase and install an evacuation chair on the second floor of the administrative building and submit proof to LPA by POC due date.
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 Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/26/2024 02:32 PM - It Cannot Be Edited


Created By: Sean Haddad On 07/26/2024 at 02:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CRESCENT LANDING AT FULLERTON MEMORY CARE
FACILITY NUMBER: 306006017

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87156(a)


87156 Licensing Fees (a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185. This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on documents, the licensee has not paid their licensing fees which are now past due, which poses a potential personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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Licensee stated that they will pay the licensing fees and submit proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024


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: CRESCENT LANDING AT FULLERTON MEMORY CARE
FACILITY NUMBER: 306006017
VISIT DATE: 07/26/2024
NARRATIVE
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During the inspection, LPA and AD observed the following: based on interviews and documents, the current administrator started in 2023 but still has not been properly designated; based on documents and admission, the facility has 35 residents all of whom have dementia and are non-ambulatory but only has a non-ambulatory fire clearance for 25; based on documents and the Licensing Information System, facility staff Jesenia D Vargas-Sandoval is not background cleared and has been working at the facility since May 28, 2024 per their staff file; based on observation, the administrative building where staff work on both floors does not have an evacuation chair; and based on documents, the licensee has not paid their licensing fees which are now past due.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Immediate civil penalties are being assessed. See LIC421IM, LIC421BG. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024
LIC809 (FAS) - (06/04)
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