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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880537
Report Date: 07/19/2024
Date Signed: 07/19/2024 02:28:19 PM

Document Has Been Signed on 07/19/2024 02:28 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CROWN ASSISTED LIVING LLCFACILITY NUMBER:
331880537
ADMINISTRATOR/
DIRECTOR:		MAE GALO, FRANCISFACILITY TYPE:
740
ADDRESS:2105 W. ONTARIO AVETELEPHONE:
(562) 881-8516
CITY:CORONASTATE: CAZIP CODE:
92882
CAPACITY: 6CENSUS: 3DATE:
07/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Administrator Mae Francis GaloTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
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Licensing Program Analysts (LPAs) Sarina Ramirez and Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPAs met with Administrator Mae Galo, and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (6), a current census of (3) residents in care and a hospice waiver for (3). LPAs conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility has no swimming pools or similar bodies of water. Outdoor shaded area is sufficient for resident activities and is enclosed with a self-latching gates. The facility has sufficient lighting and is maintained at a comfortable temperature. The facility has operating smoke detectors and carbon monoxide alarms and telephone service. Resident’s showers, toilets, and hand washing areas were operating in a safe and sanitary conditions. The hot water temperature in resident bathrooms measured at 108.4 and 108.8 degrees F. Four (4) resident’s bedrooms had beds, bed linen, chairs, storage space and sufficient lighting. The facility has sufficient linen, towels, and personal hygiene items for residents. The facility has posted in a common area, Community Care Licensing complaint poster, Ombudsman poster, facility license, facility sketch, disaster evacuation plan, emergency telephone numbers, activity calendar, and weekly menu.

Food Service: Facility kitchen and dining areas are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. Sharps, disinfectants, and cleaning solutions were kept locked and inaccessible to residents in care.

Continuation LIC809-C:

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CROWN ASSISTED LIVING LLC
FACILITY NUMBER: 331880537
VISIT DATE: 07/19/2024
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Care & Supervision: Facility has 24-hour/7days a week care staff. Facility staff have current CPR/first aid training.

Medical Related Services: Resident’s medications are labeled and centrally stored in a locked cabinet. The facility has sufficient first aid supplies.

Record Review: The Licensees' Administrator's certification is current. The facility’s last fire drill was conducted in July 2024. Three (3) Staff files reviewed were observed to be complete. LPAs review of (3) resident files observed to be complete.

Based on observations and record review, no technical violations or deficiencies were cited per Title 22, of The California Code of Regulations.

An exit interview was conducted where this report was discussed and copies were provided to Administrator Galo at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC809 (FAS) - (06/04)
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