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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006019
Report Date: 12/12/2024
Date Signed: 12/12/2024 03:27:34 PM

Document Has Been Signed on 12/12/2024 03:27 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 GARDEN GROVE MEMORY CAREFACILITY NUMBER:
306006019
ADMINISTRATOR/
DIRECTOR:		LOPEZ, DARLENEFACILITY TYPE:
740
ADDRESS:11848 VALLEY VIEW STREETTELEPHONE:
(419) 247-2800
CITY:GARDEN GROVESTATE: CAZIP CODE:
92845
CAPACITY: 72CENSUS: 54DATE:
12/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:17 AM
MET WITH:Administrator Kyle ColemanTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 12/12/2023 at 11:00 AM, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at Crescent Landing at Garden Grove Memory Care Facility. LPA Calderon was allowed entry into the facility by Administrator Kyle Coleman. The facility is licensed for 72 residents with memory care issues. Currently there are 54 resident living at the facility.

LPA Calderon explained to Administrator Kyle Coleman, the purpose of the 1-year Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: (5) resident service records, (5) resident medication records, and inspected the inside facility and outside grounds. The facilities’ last fire drill was conducted on 12/12/2024. The one-story commercial building consisting of (36) resident bedrooms, (36) resident bathrooms, (6) common bathrooms, dining room, commercial kitchen, staff room, office area, commercial washer and dryer/ storage area, backyard with umbrella with table and chairs. No weapons were found or stored on the premises. Commercial Kitchen was inspected and observed to be clean and operational. Checked commercial refrigerators and storage for 2-day supply perishable and 7-day supply of non-perishable foods are present in the facility kitchen. Emergency Water Storage was also located in the kitchen area. LPA Calderon inspected resident room A3, B4, C6, D3. LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of resident’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 GARDEN GROVE MEMORY CARE
FACILITY NUMBER: 306006019
VISIT DATE: 12/12/2024
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Bathroom #1 hot water temperature properly measured at 109 degrees Fahrenheit, and bathroom #2 hot water temperature properly measured at 107 degrees Fahrenheit. Bathroom #3 hot water temperature properly measured at 105 degrees Fahrenheit. Facility (10) Carbon Monoxide and (50) Smoke Detectors hard wired and connected were tested and are working properly. The facility (10) Fire Extinguishers were checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to residents. Medications are centrally stored and in a locked storage cabinet. Facility first aid kit is fully stocked with manual was checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to residents. Five (5) resident files were reviewed and found to be complete. LPA Calderon reviewed (5) resident medications and they were all found to be administered according to doctor's orders. Three (3) staff files were checked and have the required documents. The facility does not handle resident's money/cash resources. Commercial General Liability Policy #SB00000007244 policy period from 05/01/2024 to 05/01/2025 underwritten by Everest Indemnity Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. Administrator Coleman to email LPA Calderon a full copy of the commercial insurance policy including all endorsements no later than 12/20/2024. All the required documents are posted in the facility in a clearly visible area.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations (Located in common areas and restrooms). LPA observed staff and residents were not wearing face coverings. LPA Calderon observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA Calderon advised the Administrator Coleman to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.
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According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did not observe deficiencies therefore no citations were issued at this time. Annual Licensing Fee is CURRENT An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Kyle Coleman.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC809 (FAS) - (06/04)
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