306006019-1-10-2023-22-AS-KLYN-CMXRWS-20230110122337

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006019
Report Date: 01/10/2023
Date Signed: 01/10/2023 01:36:27 PM

Document Has Been Signed on 01/10/2023 01:36 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 GARDEN GROVE MEMORY CARE		FACILITY NUMBER:	306006019
ADMINISTRATOR:	SOTO FLORES, JESUS		FACILITY TYPE:	740
ADDRESS:	11848 VALLEY VIEW STREET		TELEPHONE:	(419) 247-2800
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92845
CAPACITY:	72	CENSUS: 43	DATE:	01/10/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:07 AM
MET WITH:	Jesus Soto		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) Kimberly Lyman made an announced visit to conduct a pre-licensing inspection. LPA identified herself and discussed the purpose of the visit with Executive Director Jesus Soto. An initial application to operate a Residential Care Facility for the Elderly was received by CCL for a capacity of thirty eight non-ambulatory and thirty four ambulatory residents. Facility has a covid screening area in the entrance of the facility. LPA observed ample PPE supply in the facility. LPA Lyman along with Executive Director toured the facility at 10:20 AM and observed the following: Structure: Facility is a one story building with delayed egress exits specializing in memory care. Facility is "U" shaped around a courtyard. Facility has multiple activity areas as well as a beauty salon. Common Areas: Adequate seating is available for residents and visitors. Bedrooms Residents: Rooms are single and double occupancy. All rooms are equipped with appropriate lighting, furnishings and ample closet space. Bathrooms: All resident bathrooms have a working toilet/ wash basin as well as grab bars. Facility has sanitizer/ soap in the restrooms and disposable paper towels. Facility utilizes common shower rooms as well for residents. Linens & Hygiene Supplies: Facility has ample bedding and towels for residents in care. Emergency Phone Numbers and Exit Plan: Posted in entrance of facility. Food Service: Facility has ample 2 day perishables and 7 day non-perishables. Freezers and refrigerator temperatures are monitored daily and LPA observed documentation. Smoke Detectors: Carbon monoxide detectors tested operational during today's visit. Outside agency, Cal Building Systems, conducted the last smoke detector inspection on 08/03/2022. Fire Marshall conducted an annual visit on 12/01/2022 with no concerns noted. Fire extinguishers are mounted and charged. Appliances: Kitchen appliances as well as washers and dryers are clean and operational. Toxins/ Sharps: Facility has toxins and sharps secured. Water Temperature: Tested and recorded between 112.6 and 120 degrees F. in facility bathrooms. Emergency Supplies: LPA observed ample emergency food and water in the facility as well as emergency supplies. Medications, First-Aid Kit & Book: Facility has multiple first aid kits which contained required items. Medication is stored and locked in medication carts. Facility uses an electronic medication record. CONT ON LIC 809C DATED 01/10/2022.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023

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: CRESCENT LANDING AT GARDEN GROVE MEMORY CARE	FACILITY NUMBER: 306006019
	VISIT DATE: 01/10/2023

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Resident & Staff File: Resident records are stored in medication room. Staff files are stored in the business office. Reading Material, Games, and Equipment: LPA observed posted daily activity schedule with activities such as exercise, arts and crafts, and gardening. Outside areas: LPA observed multiple outdoor shaded areas for visiting. Fire Clearance: Approved for thirty eight non-ambulatory residents and thirty four ambulatory residents on 09/14/2021.

During the visit, LPA observed the following:

The "Let Us No" poster is not regulation size. Please post 20" X 26."
Facility does not have a menu posted. Please post menu.

Component III waived during visit as Executive Director is an experienced Administrator. Executive Director to notify LPA when corrections have been made.

Facility is ready to be licensed.

Exit interview conducted and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023

LIC809 (FAS) - (06/04)

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