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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006018
Report Date: 06/06/2024
Date Signed: 06/06/2024 02:05:54 PM


Document Has Been Signed on 06/06/2024 02:05 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 COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:CRESCENT LANDING AT SOUTH COAST MEMORY CAREFACILITY NUMBER:
306006018
ADMINISTRATOR:TORRES, JUDITHFACILITY TYPE:
740
ADDRESS:3730 S. GREENVILLE AVENUETELEPHONE:
(419) 247-2800
CITY:SANTA ANASTATE: CAZIP CODE:
92704
CAPACITY:72CENSUS: 45DATE:
06/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:49 PM
MET WITH:Judith Torres-AdministratorTIME COMPLETED:
02:26 PM
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted a case management visit to follow up on an incident report received by Community Care Licensing (CCL) on 04/19/24. LPA was greeted and allowed entrance into the facility by Administrator (AD) Judith Torres. LPA explained the reason for the visit.

LPA and AD conducted a toured of the facility. During today's visit LPA interview the AD.

Incident report dated 04/19/24 states that on 04/15/24 Resident 1 (R1) was noted with a bruise to their left arm after returning from an outing with family.

Records reviewed by LPA Ramirez included the Skin Monitoring: PCA Shower Review dated 04/17/24 for R1. Per Skin monitoring R1 had a bruise to their left arm.

During the visit LPA interview AD who reported that the bruise looked like a mark from a hand holding the resident's arm. AD reported that the Primary Care Physican (PCP) was notified and stated that R1 did not need medical attention.


An exit interview was conducted with AD Torres and a copy of this report was provided at the time of exit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
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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