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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005642
Report Date: 10/07/2025
Date Signed: 10/07/2025 01:12:23 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
11/23/2022 and conducted by Evaluator Ruth Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221123081721
FACILITY NAME:CROWN COVEFACILITY NUMBER:
306005642
ADMINISTRATOR:KAMESHI TAYLORFACILITY TYPE:
740
ADDRESS:3901 EAST COAST HIGHWAYTELEPHONE:
(949) 760-2800
CITY:CORONA DEL MARSTATE: CAZIP CODE:
92625
CAPACITY:97CENSUS: 69DATE:
10/07/2025
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Janette Hill, Executive DirectorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff are not providing proper medication assistance to resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude investigation into the above identified complaint allegation. LPA spoke with Janette Hill, Executive Director Executive Director, and explained the purpose of the visit.

Findings are based upon this investigation which included tour of the facility, facility file review, resident file review, copies or perteinent documents and interviews conducted.

It is alleged staff are not providing proper medication assistance to resident (R1) in care. Interview with 2 of 2 staff stated there had been issues with medication and that as of November 30, 2022, they were made aware that there was medication that was not being administered. Records revealed in review of

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
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-20221123081721
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: CROWN COVE
FACILITY NUMBER: 306005642
VISIT DATE: 10/07/2025
NARRATIVE
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MAR (medication administration records from September 1, 2022, to November 30, 2022, reflect that R1 had 9 medications on record and all 9 medications have missed doses on several dates throughout the 3 month period reviewed. Missed doses are observed on multiple dates and/or multiple times for one day as missed or not administered.

During the course of the investigation, there was sufficient evidence to substantiate the allegation. The preponderance of evidence standard has been met; therefore, the above allegation is SUBSTANTIATED. See LIC9099-D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Executive Director and a copy of this LIC9099 and LIC9099-D, along with a copy of the appeal rights was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20221123081721
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: CROWN COVE
FACILITY NUMBER: 306005642
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2025
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidence by: based on documents and interviews,
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Executive director stated they will provide in-house medication training with all staff on cited regulation and addressing importance of giving the residents their medication as prescribed. The proof of training will be submitted to the LPA via email POC date.
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the staff did not ensure R1 received their medication as prescribed on multiple days and times. R1 missed multiple doses for 9 medications from September 1, 2022 to November 30, 2022. This poses an immediate health and safety risk 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: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
11/23/2022 and conducted by Evaluator Ruth Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221123081721

FACILITY NAME:CROWN COVEFACILITY NUMBER:
306005642
ADMINISTRATOR:KAMESHI TAYLORFACILITY TYPE:
740
ADDRESS:3901 EAST COAST HIGHWAYTELEPHONE:
(949) 760-2800
CITY:CORONA DEL MARSTATE: CAZIP CODE:
92625
CAPACITY:97CENSUS: 69DATE:
10/07/2025
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Janette Hill, Executive DirectorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff are not providing proper shower assistance to resident in care.
Staff are not providing proper food service to resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude investigation into the above identified complaint allegations. LPA spoke with Janette Hill, Executive Director and explained the purpose of the visit.

Findings are based upon this investigation which included tour of the facility, facility file review, resident file review, copies of pertinent documents, and interviews conducted.

It is alleged that staff are not providing proper shower assistance to resident (R1) in care. Record review reflects that facility uses a shower schedule for residents in the memory care where R1 resides. The shower schedule reflects two shower schedules for R1 for twice a week showers. Schedule and log

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20221123081721
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: CROWN COVE
FACILITY NUMBER: 306005642
VISIT DATE: 10/07/2025
NARRATIVE
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reflect the residents in memory care that received showers and the time. Shift logs for August 2022 to November 2022 reflect R1 to be receiving showers, refusing showers, and staff insisting for R1 to shower without success. Interview with staff stated that when a resident refuses to shower they check back with residents 3 times. Interview with 4 of 4 residents stated that they get help with showers, and they have never had an issue with getting a shower.

It is alleged that staff are not providing proper food service to resident in care. Record review reflects that shift logs for August of 2022 to November of 2022 R1 has refused to eat meals on several times throughout the day as well reflects when and how much R1 ate for meals throughout the day. Interview with staff stated that when a resident refuses meals they check back with them 3 times for them to eat. Interview with 4 of 4 residents stated that they get their meals, staff bring them meals and/or staff help them with their meals.

Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

An exit interview was conducted with the Executive Director and a copy of this LIC9099 report was left at facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5