Crown Cove

Based on observations and records reviewed the licensee did not comply with the cited above as Resident 3 listed on LIC 858. Resident 3 is noted as bedridden, the faciltiy is not licensed to accept bedridden residents. This poses an immediate health and safety risks.

Based on observations and records reviewed the licensee did not comply with the cited above in 2 out of 6 staff members files reviewed. This poses an immediate health and safety risk to persons in care.

Based on records reviewed the licensee did not comply with the cited above in 6 out of 6 staff did not have the required 4 hours of training on the following : postural support, restricted health conditions and hospice care. This poses a potential health and safety risk to persons in care.

Based on observations made licensee did not comply with the cited above. LPA Mendivil and LPA Lyman observed 3 cases of water for the entire building. This poses a potential health and safety risk to persons in care.

Based on records reviewed and observation the licensee did not comply with the cited above as the last signature for review was in 2022 from previous executive director. This poses a potential health and safety risk to persons in care.

Based on observations the licensee did not comply with the cited above as the laundry room in Memory Care was unlocked the toxins in the room were also unsecured. This poses an immediate health and safety to persons in care.

Based on records reviewed and observations the licensee did not comply with the cited above, per Non Compliance Conference held on 09/05/2025, Licensee agreed to maintain a staffing ratio of 1 caregiver to 7 residents, per review there are 18 residents in Memory Care and only 2 caregivers. This poses an immediate health and safety risks to persons in care.

Based on records reviewed the licensee did not comply with the cited above in 3 out of 9 residents as their LIC 602 Physician's Report for Resident 3, Resident 6 and Resident 7 listed on LIC 858-C over a year old. This poses an immediate health and safety risk to persons in care.

Based on observations the licensee did not comply with the cited above as there was no PUB poster in the faciltiy. This poses a potential personal rights risk to persons in care.

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, 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

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... 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.

(e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement was not met as evidence by facility did not obtain Medication Administration Records from 2023.

Observation of the Resident. ... When changes … are observed, the licensee shall ensure that such changes are documented and brought to the attention of … the resident's responsible person, if any. This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not ensure R1’s worsening skin condition was noted and brought to the attention of their responsible party, which poses a potential health risk to persons in care.

87468.1 Personal Rights of Residents in All Facilities. (a) … (6) To leave or depart the facility at any time... This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not licensee did not ensure that R1 was free to leave or depart from the facility without being forced to quarantine in their room upon return, which poses an immediate personal rights risk to persons in care.

87468.1 Personal Rights of Residents in All Facilities (a) … (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not ensure R1 had safe, healthful, and comfortable accommodations by permanently closing their window, which poses a potential personal rights risk to persons in care.

87465 Incidental Medical and Dental Care. (a) … (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents… This requirement was not met as evidenced by Based on documents and interviews, the licensee did not ensure R1, who had known skin issues, received proper assistance and medical care resulting in R1 developing an unstageable wound, which poses an immediate health risk to persons in care.

87465 Incidental Medical and Dental Care. (a) … (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by Based on documents and interviews, the licensee did not ensure R1 received multiple medications as prescribed, which poses an immediate health risk to persons in care.

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision... This requirement was not met as evidenced by: Based on interview and documents, the licensee did not provide adequate supervision to R1 when R1 left the facility without assistance, which posed an immediate safety risk to persons in care.

Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not being met as evidenced by: Based on record review and interviews conducted, Licensee failed to ensure staff training verification is maintained in personnel records. This poses a potential health and safety risk to residents in care.