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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607753
Report Date: 10/14/2022
Date Signed: 10/14/2022 02:01:43 PM

Document Has Been Signed on 10/14/2022 02:01 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CROWN MANORFACILITY NUMBER:
197607753
ADMINISTRATOR:KEVIN MATTHEW BIMFACILITY TYPE:
740
ADDRESS:15327 CAMPILLOS ROADTELEPHONE:
(714) 743-7516
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 6CENSUS: 5DATE:
10/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Administrator Kevin BimTIME COMPLETED:
01:00 PM
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Licensing Program Analyst/ (LPA) Jose Villalobos conducted an unannounced annual inspection visit focused on Infection Control Domain. LPA was by staff Gloria Romulo and the purpose of the visit was discussed. Administrator Kevin Bim arrived shortly after.

As a part of the inspection, LPA used the inspection tool, reviewed (5) resident records, (3) staff files, and (5) client medications. The facility is licensed for six (6) residents age 60 and over, of which may include (5) non-ambulatory residents, (1) bedridden, and (3) hospice care. The facility is a one story house located in a residential neighborhood consists of (3) resident bedrooms, (2) resident bathrooms, (1) staff room, family room, dining room, kitchen, attached garage/ storage area, enclosed patio with table and chairs. LPA toured the physical plant and was observed to be clean and operational. A 2-day supply perishable and 7-day supply of non-perishable foods are present in the facility. Emergency Water and food is located in the garage. LPA observed that all facility rooms are clean and in good repair. The facility has central air and heating. LPA observed all bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA 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 observed bathrooms were found to be within Title 22 regulation. Facility Carbon Monoxide and Smoke Detectors were tested and working properly. 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. 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. Visit was completed using the Inspection Tool and LPA did not observe deficiencies therefore no citations were issued at this time.

An exit interview was conducted and a copy of the Facility Evaluation Report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2022
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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