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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005642
Report Date: 05/30/2025
Date Signed: 05/30/2025 10:01:11 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/21/2025 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250121161311
FACILITY NAME:CROWN COVEFACILITY NUMBER:
306005642
ADMINISTRATOR:JANETTE HILLFACILITY TYPE:
740
ADDRESS:3901 EAST COAST HIGHWAYTELEPHONE:
(760) 547-2863
CITY:CORONA DEL MARSTATE: CAZIP CODE:
92625
CAPACITY:97CENSUS: 68DATE:
05/30/2025
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Janette Hill - Executive Director TIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Resident sustained a severe burn as a result of neglect
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility and explained the reason for the visit.

The Department received a complaint on January 23, 2025, and the initial 10-day visit was conducted that same day by LPA Mendivil. LPA Mendivil obtained copies of documents including physician’s reports, needs and services, medication records and admission agreements. Regarding the allegation resident sustained a severe burn as a result of neglect, the investigation revealed the following:

It was alleged that Resident 1 (R1) had sustained a severe burn as a result of neglect. Based on physician’s report dated December 23, 2023, R1 has a history of skin breakdown and was listed as able to feed themselves. Per review of Senior Living Standard Level of Care and Services Plan dated September 11, 2024, it was reported that R1 needed assistance with eating. Review of emails between the facility and R1’s hospice nurse suggested that R1 be given finger foods to make eating easier for them.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 22-AS-20250121161311
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: CROWN COVE
FACILITY NUMBER: 306005642
VISIT DATE: 05/30/2025
NARRATIVE
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Interviews with 8 out of 8 staff stated that R1 was not able to hold utensils on their own. It was also reported that due to the R1’s inability to hold utensils the resident would spill food on themselves during mealtimes. On November 28, 2024, R1 was visited by their family member, who reported they did not observe any burns on R1. The following day, on November 29, 2024, Witness interviews reported that R1 had burns on their chest. Photographic images obtained confirmed injuries on R1’s chest along with Facility progress notes dated November 29, 2024, in which staff notated that resident had a popped blister on their chest and small blisters on their chin. At the time of incident, R1 reported they had spilled coffee on themselves. Per interviews it was reported that R1 was given a cup of coffee at some point on November 28, 2024; However, no staff could confirm who provided R1 with the cup of coffee. Staff interviews did confirm stains on R1’s clothing around the suspected time of incident. R1’s blistered was treated by their Hoag at Home Hospice Nurse on November 29, 2024, who reported the blister had green drainage indicating an infection. Hoag at Home Hospice Nurse denied that any of R1’s underlying conditions could have caused the blisters.

Therefore, based on the preponderance of evidence through records reviewed and interviews the allegation that resident sustained a severe burn as a result of neglect is determined to be Substantiated, meaning the complaint allegation is valid and that a violation has occurred.



See LIC9099-D for cited deficiencies and immediate civil penalty as per Title 22 Division 6 of the California Code of Regulations. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49 (f)

An exit interview was conducted with Kasan Soewono, Culinary Service Director. A copy of this report, along with LIC9099-D, Appeal Rights, Civil Penalty Assessment-LIC 421 IM and the LIC 811, identifying confidential names were provided and explained.”
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/21/2025 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250121161311

FACILITY NAME:CROWN COVEFACILITY NUMBER:
306005642
ADMINISTRATOR:JANETTE HILLFACILITY TYPE:
740
ADDRESS:3901 EAST COAST HIGHWAYTELEPHONE:
(760) 547-2863
CITY:CORONA DEL MARSTATE: CAZIP CODE:
92625
CAPACITY:97CENSUS: DATE:
05/30/2025
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Janette Hill - Executive Director TIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff did not administer medications to resident as prescribed.
Staff did not ensure resident's room was cleaned.
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility and explained the reason for the visit.

The Department received a complaint on January 23, 2025, and the initial 10-day visit was conducted that same day by LPA Mendivil. LPA Mendivil obtained copies of documents including physician’s reports, needs and services, medication records and admission agreements. Regarding the allegations staff did not administer medication to resident as prescribed and staff did not ensure the resident’s room was cleaned, the investigation revealed the following:
It was alleged Resident 1 (R1) was not getting medications as prescribed. Per review of R1’s Medication Administration Record (MAR) medications were given as prescribed, and PRNs were notated on MAR. A current audit comparing R1’s medications and records on file could not be conducted as R1 passed away on December 27, 2024.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20250121161311
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: CROWN COVE
FACILITY NUMBER: 306005642
VISIT DATE: 05/30/2025
NARRATIVE
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 Per interviews with 2 out of 6 staff stated they give residents medication as prescribed, 4 of the staff members interviewed did not have direct knowledge of medication administration.

Regarding the allegation staff did not ensure the resident’s room was cleaned. Interviews with 5 out of 5 residents stated the resident’s rooms are cleaned. Based on interviews with 6 out of 6 staff stated the facility and resident’s rooms are clean. During LPA Mendivil’s initial visit on January 23, 2025, LPA toured the interior of the facility and observed clear and uncluttered walkways and the facility to be free of dust and odors.

Therefore, based on the preponderance of evidence through records reviewed and interviews the allegations that staff did not administer medication to resident as prescribed and staff did not ensure the resident’s room was cleaned are determined to be UNSUBSTANTIATED, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

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: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20250121161311
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: CROWN COVE
FACILITY NUMBER: 306005642
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/02/2025
Section Cited
CCR
87464(f)(1)
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Basic Services. Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by Licensee did not ensure R1...
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Executive Director to conduct in services about residents needs in dining and potential use of adaptive utensils/cups.

Immediate Civil Penalty issued *
Manual 421IM form used due to technical difficulties
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was assisted with food services resulting in R1 reporting they spilled coffee or hot liquids on themselves. As a result, R1 sustained blisters on their chest. This poses an immediate health and safety risks to persons in care.
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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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5