Crown Cove.

On this day, Licensing Program Analysts (LPAs) Andrea Mendivil and LPA Kimberly Lyman made an unannounced visit to conduct a required annual. LPAs were greeted and granted entry into the facility by staff and explained the reason for the visit. The facility is a three level building with an approved fire clearance of nine ambulatory; eighty-eight non-ambulatory residents of which fifteen are approved for hospice. The facility currently has a census of 72 residents in care. LPAs toured the facility and inspected the physical plant, including but not limited to testing hot water temperature in the bathrooms. The hot water temperature measured 108.6 and 117.6 degrees Fahrenheit. The facility uses Cal Building Systems for smoke directors and fire sprinkler service and the last inspection was conducted on 03/18/2025. The facility conducted an emergency drill on 10/14/2025. LPAs inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPAs observed 3 cases of water in the underground parking structure for emergencies. LPAs reviewed 9 resident files, Residents 3, 6 and 7 did not have updated LIC 602 Physicians Report. LPAs reviewed 6 staff files and no staff had CPR or first aid training. LPAs observed staff did not have the annual training that includes 4 hours of training on the following topics: postural support, restricted health conditions and hospice care LPAs observed unsecured laundry room in Memory Care that contained an unsecured cabinet with toxins. LPAs did not observe PUB 475 in the entryway of the facility. LPAs observed Resident 3 who is listed as bedridden in a room that is not cleared for bedridden resident. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Per Non Compliance Conference held on 09/05/2025 , Licensee agreed to maintain a staffing ration of 1 caregiver to 7 residents, per review there are 18 residents in Memory Care and only 2 caregivers on shift today. The following is being cited per Title 22. An exit interview was conducted and a copy of this report, LIC 858 and appeal rights were provided.

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. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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.

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.” 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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

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.

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20201103132810. LPA met with Administrator (AD) Janette Hill and discussed the purpose of the inspection. During the course of the investigation, LPA interviewed a witness who stated that Resident #1 (R1) complained to the facility that due to a broken window their room, they were not able to open or close the window when needed to regulate the temperature in their room and that the facility’s response was to screw the window permanently shut. LPA reviewed a photograph of the window showing a screw in place to prevent the window from opening. LPA interviewed AD who stated there were likely two windows at the time. LPA inspected R1’s former room and noted there are two windows and both windows currently function properly. LPA reviewed the facility’s emergency disaster exit plan which does not indicate that windows would be used in an emergency and also observed that R1’s room was close to the stairs and a small balcony that can be entered using a full-size door. It is unclear whether only one window or both were alleged to have been screwed shut and the information obtained does not corroborate that screwing one window shut would have negatively affected a fire evacuation. However, permanently closing the window interfered with R1’s comfort and enjoyment of their room. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

R1’s Hoag Hospital Medical Records dated March 15, 2020, R1’s Primary Care Medical Records dated January 20, 2020, and Medication Administration Records for 2020. Regarding the allegation that the facility did not provide treatment to resident with stage 3 pressure and ankle injury: it was alleged that R1 developed a stage 3 pressure injury on their left ankle at the facility and did not receive proper treatment. LPA interviewed a witness who stated that prior to entering the facility on January 1, 2020, R1 did not have a pressure injury, but on August 16, 2020, while at an urgent care for ankle swelling, an ankle bandage over R1’s left ankle was removed and R1’s stage 3 pressure injury was first discovered and R1 was referred to wound care. LPA reviewed Photographs of R1 showing the ankle bandage on August 14, 2020, the status of R1’s ankle wound on August 16, 2020, and the current status of R1’s legs and ankles. LPA reviewed R1’s Home Health Medical Records dated December 29, 2020, which corroborate that R1 had an unstageable pressure injury on their left ankle as of August 22, 2020, which had not healed by November 18, 2020, and that home health was initiated on July 27, 2020, but that the pressure injury was not originally in the care plan as of that date. LPA reviewed R1’s Home Health Medical Records dated January 21, 2021, which corroborate that R1 had an unstageable pressure injury on their left ankle as of November 25, 2020, which became a stage 3 pressure injury on January 6, 2021. When interviewed, a former administrator stated that R1 had a skin tear, facility staff were providing treatment, home health was initiated on July 26, 2020, and home health provided wound care to R1 but did not indicate the stage of the wound, and the facility reported the issue to R1’s responsible party at an unknown date. LPA reviewed R1’s Physician’s Report dated December 27, 2019, which states that R1 has a history of left ankle cellulitis. LPA reviewed R1’s Assessment dated December 31, 2019, which indicates R1 has no skin breakdown but has healing wounds and is able to completely self-manage the condition. LPA reviewed R1’s Preplacement Appraisal dated January 1, 2020, which does not mention any issues with skin or wounds. LPA interviewed a former administrator who stated that that R1 had healing wounds documented as of February 22, 2020, and the goal was improved healing of the wound. LPA reviewed R1’s Service Plan dated March 25, 2021, which states that as of February 22, 2020, R1 has healing wounds but is able to completely self-manage the condition. LPA reviewed R1’s Assessment dated February 28, 2020, which indicates R1 has no skin breakdown and no healing wounds or bedsores. LPA reviewed R1’s Assessment dated October 16, 2020, which indicates R1 requires regular staff evaluation and assistance in managing skin care needs and has a healing wound and requires staff monitoring and assistance. Based on the information obtained, R1 had a known history of skin issues but due to lack of care, oversight, and treatment, R1’s skin issues worsened and R1 developed an unstageable pressure injury while in care which eventually became a stage 3 pressure injury. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Regarding the allegation that the facility did not report pressure/ankle injury to resident's responsible party: it was alleged that the facility did not notify R1’s responsible party of R1’s stage 3 pressure injury. LPA interviewed a witness who stated that R1’s responsible party had no notice of R1’s pressure injury until it was discovered at an urgent care on August 16, 2020. When interviewed, a former administrator stated that the facility reported R1’s skin issue to R1’s responsible party at an unknown date. LPA reviewed R1’s Home Health Medical Records dated December 29, 2020, which corroborate that R1’s stage 3 pressure injury was not reported by the facility as R1’s home health plan of care and list of diagnoses did not include any pressure injuries as of July 27, 2020. Instead, R1’s unstageable pressure injury was added to R1’s home health plan of care and list of diagnoses on August 22, 2020, only after the pressure injury was discovered at an urgent care on August 16, 2020. Based on the information obtained, R1 developed an unstageable pressure injury at the facility and R1’s reporting party was not timely notified. Regarding the allegation of resident denied visitation from responsible party: it was alleged that during the facility’s COVID-19 lockdown, R1’s responsible party was not allowed to visit R1 in person for three months. LPA interviewed a witness who stated that the facility imposed a mandatory quarantine for any resident that left the facility for any reason, regardless of symptoms or exposure, R1 went to the hospital on March 15, 2020 and returned the same day and R1’s responsible was not allowed to visit R1 on that day, on March 18, 2020, or on March 24, 2020 due to the quarantine, and R1’s responsible party was advised that if R1 went outside the facility to see them R1 would have to be quarantined for another 14 days. When interviewed, a former administrator stated that the facility was not allowing visitation, but was allowing window visits. LPA interviewed another former administrator who reported that the policy around March 15, 2020 was that residents had to isolate for 14 days after leaving the facility. LPA reviewed California Department of Social Services Provider Information Notice (PIN) 20-07-ASC, effective March 13, 2020, which states that, as prevention measures, facilities should restrict visitors, where there are COVID-19 confirmed cases in the surrounding community, and limit resident activities outside of their rooms. However, this PIN does not allow for the isolation of a resident unless the resident has a known exposure or is displaying symptoms of COVID-19. PIN 20-08-ASC, effective March 18, 2020, superseded, PIN 20-07-ASC, but does not change this guidance. LPA reviewed R1’s Hoag Hospital Medical Records dated March 15, 2020, which do not indicate R1 was exposed to or symptomatic for COVID-19. Based on the information obtained, the facility was not following the applicable PIN by requiring isolation of residents and not allowing outdoor visits. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Regarding the allegation that facility staff missed dosages of medication: it was alleged that there were multiple instances where R1’s medication times were missed. LPA interviewed a witness who stated that they observed R1 not receiving their medication on time and that the medications would be given hours late which would cause R1 to be groggy. LPA reviewed R1’s Primary Care Medical Records dated January 20, 2020, which indicate that R1’s doctor recommended R1’s Parkinson’s Disease medication be administered at 8AM, 1PM, and 6PM and that the medication will wear off after 5 hours and make R1 a higher fall risk. LPA interviewed a former administrator who was unable to provide information about this allegation. LPA reviewed R1’s Medication Administration Records for 2020 which show multiple instances of R1’s Parkinson’s Disease medication, Carbidopa-Levodopa, and other medications not being signed off by facility staff as having been given to R1 and that R1 did not receive their Trazodone and other medications for extended periods of time because the medications were not available. LPA obtained information corroborating that facility staff missed multiple doses of R1’s important medications that could have led to increased fall risk and other serious issues. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Regarding the allegation that staff did not call 911: it was alleged that during an emergency, facility staff did not call 911 but instead called R1’s responsible party to request permission to call the paramedics. LPA interviewed a witness who stated that on the morning of March 15, 2020, facility staff had checked on R1 at 6:30AM and 8:00AM but could not wake R1 and should have called 911 then, but instead waited until 10:20AM to call R1’s responsible party to ask for permission to call 911 which was given. However, LPA did not obtain information corroborating that facility staff observed R1 having a medical emergency at 6:30AM or 8:00AM. LPA reviewed the facility’s Internal Incident Reports for R1 and did not find an incident report for this date. LPA interviewed a former administrator who was unable to provide information about this allegation. LPA reviewed R1’s Hoag Hospital Medical Records dated March 15, 2020, which indicate R1 made to the hospital by 11:32AM, was alert with no distress, was not diagnosed with any medical conditions, and was released the same day with no new diagnoses. LPA did not obtain information corroborating the length of delay or that R1 sustained any serious injury as a result of this incident or any delay in the facility seeking care for R1. Regarding the allegation that facility staff overmedicated resident: it was alleged that R1 suffered a fall at the facility, went to the hospital, and the emergency room physician and R1’s physician verbally stated they thought R1 must have been overmedicated. LPA interviewed a witness who was told by the emergency

This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of a health and safety check and to follow up on a self-reported incident report received in the Orange County Regional Office (OCRO) on 10/25/23 regarding Resident #1 (R1). LPA met with Administrator (AD) Carrie Galloway and discussed the purpose of the inspection. The incident report states the following: On 10/20/23, R1 left the facility to go on a walk, walked for about a mile, sat down on a bench, was offered a ride and returned to the facility by a local member of the community, and sustained no injuries. During today’s inspection, LPA conducted a health and safety check on R1 and observed no health and safety issues. LPA observed the facility to be clean and organized and found no health and safety issues. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food, the electricity and water were running, the facility had soap and paper towels, and the medications and sharps were properly stored. LPA confirmed placement of door alarms in the memory care unit. LPA interviewed AD and requested and reviewed copies of the resident roster, staff roster, and R1’s resident file. The investigation into the incident revealed the following: Per R1’s Physician’s Report dated 06/16/23, R1 does not have dementia but is not able to leave the facility unassisted. Per AD, at the time of the incident, R1 resided in the assisted living section of the facility. However, after the incident, R1 obtained a new Physician’s Report dated 10/26/23 which states R1 does have dementia and is not able to leave the facility unassisted. R1 now resides in the memory care unit. CONTINUED. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Per AD, R1 left the facility through the front door stating they were going for a walk and this was not unusual because R1 is part of a walking club. After the incident, the facility added motion alarms on the front entryway, created an updated list of residents who are unable to leave the facility unassisted for staff to be aware, and conducted training for front door staff on residents leaving without assistance. LPA confirmed all these items during the inspection. Based on the information obtained during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

Eight out of ten staff/ witnesses deny a lack of incontinence care for any residents. Six out of six staff/ witnesses deny either observing bruises on R1 or indicated a bruise was from the integrity of the resident's skin due to the resident's condition and deny abuse. LPA observed residents dining at lunch time in the common area of the memory care unit. All staff interviewed indicated residents are brought out of their rooms for meals and witnesses corroborate this. Memory care unit averages a census of 13-14 residents daily. Facility schedule indicates staffing as follows: 2-3 caregivers/ 2 med techs/ Resident Services Director on first shift, and 2 caregivers/ 1 med tech on second shift and NOC shift. Facility has a full time nurse as well. Five out of eight staff/ witnesses indicate facility has suffered with staffing shortages but staffing levels appear better now. Three out of eight staff/ witnesses state there were not always two people available for a two person assist for R1. Due to conflicting information, LPA is unable to corroborate the allegations. Based on interviews conducted and observation during a tour of the memory care unit, the allegations are deemed to be Unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violations did occur. An exit interview was conducted and a copy of this report was provided to a facility representative.