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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006017
Report Date: 09/18/2024
Date Signed: 09/18/2024 11:08:29 AM


Document Has Been Signed on 09/18/2024 11:08 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:CRESCENT LANDING AT FULLERTON MEMORY CAREFACILITY NUMBER:
306006017
ADMINISTRATOR:JESUS SOTOFACILITY TYPE:
740
ADDRESS:1510 E. COMMONWEALTH AVENUETELEPHONE:
(419) 247-2800
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY:72CENSUS: 39DATE:
09/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Jesus SotoTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced Case Management visit to follow up on an Incident Report received by Community Care Licensing (CCL) on 09/17/2024. LPA met with Administrator (AD) Jesus Soto and RaeAnn Carbal, Health Services Director (HSD) and explained the reason for the visit.

LPA interviewed AD Soto and HSD Carbal regarding the circumstances of the reported incident.

Incident was self reported via telephone on 09/16/2024. Incident reported stated Resident 1 (R1) was found with both wrist tied together with a strap with about five inches apart on 09/15/2024 at approximately 10:34 pm by Staff 1 (S1). S1, reported the incident to Resident Care Coordinator Mellody Aliado who then reported incident to the AD Soto immediately. An in-house investigation was started that same night and Staff 2 (S2) confessed to restraining R1 to prevent R1 from eating R1's poop.

Staff 2 who confessed to restraining R1 was suspended pending the result of their investigation and was not present during LPA's visit. Staff 2 is associated and cleared in Guardian.

LPA, along with HSD Carbal conducted a tour of the physical plant and visited R1 who was in the dining room. R1 appeared well kempt with no apparent signs of distress or injuries observed. Facility is undergoing some renovation. Facility was observed clean, safe and sanitary. Residents were observed relaxing in their room or in dining room, No health and safety concerns noted during the visit.

LPA requested and obtained the facility's current census, employee roster (LIC500), staff training, as well as most recent physician report and Service Plan for R1.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with AD Soto and a copy sent to email on file.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 705-6004
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024
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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