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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005642
Report Date: 01/27/2025
Date Signed: 01/28/2025 07:54:02 AM

Document Has Been Signed on 01/28/2025 07:54 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CROWN COVEFACILITY NUMBER:
306005642
ADMINISTRATOR/
DIRECTOR:		JANETTE HILLFACILITY TYPE:
740
ADDRESS:3901 EAST COAST HIGHWAYTELEPHONE:
(760) 547-2863
CITY:CORONA DEL MARSTATE: CAZIP CODE:
92625
CAPACITY: 97CENSUS: 59DATE:
01/27/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Janette Hill - Executive Director TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On this day, Licensing Program Analysts (LPAs) Andrea Mendivil and Kimberly Lyman made an unannounced visit in conjuction with a complaint investigation for complaint control # 22-AS-20231117101241. LPAs were greeted and granted entry into the facility by Gerrardo Garibay and explained the reason for the visit. Executive Director Janette Hill arrived shortly after.

During the course of investigation LPA Mendivil requested a copy of either electronic/written Medication Administration Record for October 2023 to November 2023. Per conversation with Executive Director Janette Hill stated they were unable to locate the Medication Administration Records from 2023.

Based on observations a deficiency is being cited per California Code of Regulations Title 22. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025
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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Document Has Been Signed on 01/28/2025 07:54 AM - It Cannot Be Edited


Created By: Andrea Mendivil On 01/27/2025 at 02:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CROWN COVE
FACILITY NUMBER: 306005642

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/02/2025
Section Cited
CCR
87506(e)

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(e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement was not met as evidence by facility did not obtain Medication Administration Records from 2023.
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Executive Director agreed to file all records in one central location and will conduct in services. Executive Director will provide proof by POC due date.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2025


LIC809 (FAS) - (06/04)
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