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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425653
Report Date: 02/14/2023
Date Signed: 02/14/2023 04:30:02 PM

Document Has Been Signed on 02/14/2023 04:30 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CROWN MANOR IIFACILITY NUMBER:
336425653
ADMINISTRATOR:AGNES MARTINEZFACILITY TYPE:
740
ADDRESS:34153 ALBACETE AVENUETELEPHONE:
(951) 246-7220
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY: 6CENSUS: 5DATE:
02/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Licensee, Agnes MartinezTIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to conduct a case management visit regarding incident reports that were sent to the department on 02/07/2023. LPA met with Licensee, Agnes Martinez who was informed of the purpose of the visit. At the time of the visit there were (5) residents and (4) staff present.

LPA conducted a tour of the interior and exterior of the facility. LPA observed that the staff and resident files were being kept locked in the facility office area. LPA observed that the resident medication were locked in facility pantry cabinets. LPA reviewed the Guardian roster and staff transfer sheets and confirmed that the staff present had a background clearance and had sent transfer requested on 2/13/2023. No health and safety issued were observed during the time of the visit.

Incident reports sent to the regional office stated that on 1/25/2023 a third party had informed the licensee that Staff #1 (S1) and Staff #2 (S2) had been speaking with responsible parties of the Resident 1 (R1) and Resident 2 (R2) about moving the residents to another facility. Through interviews, LPA found that the licensee had spoken with staff on the issue who had denied it.

Incident on 02/02/2023 stated that licensee had visited the facility and noted that S1 had left without informing the licensee. One (1) staff was caring for the facility residents. Licensee stayed to assist on that day. Staff files, keys, and S1, S2, and Staff #3's belongings were found to be missing.

Incident on 02/05/.2023 stated that licensee had noted that Resident #3 (R3)'s medication had been given to S1 on 1/31/2023 and was missing. The licensee contacted police on stolen items and incident #23-038-121 had been filed.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CROWN MANOR II
FACILITY NUMBER: 336425653
VISIT DATE: 02/14/2023
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During the visit, LPA conducted interview, documented observations, and collected documents. The licensee was advised on the documents that would need to be sent to LPA by the end of the business day 2/17/2023.

Based on the information reviewed, LPA will be issuing a technical violation for licensee to make a written plan on how the facility plans to safe guard the facility's and resident's belongings. LPA will also be documented a technical violation for licensee to make a written plan on how the administrator and licensee plan on being present at the facility to ensure proper care and supervision of residents is being provided as well as supervision of staff activities. Technical advisory note will be documented for S1, S2 and S3 to be disassociated from facility roster. All these must be completed and sent to LPA by close of business 2/17/2023.

An exit interview was conducted where this report along with LIC9102 TV pages were reviewed and provided to Licensee, Agnes Martinez.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023
LIC809 (FAS) - (06/04)
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