Inspection Reports for Crown Cove

The inspection was an unannounced complaint investigation visit triggered by allegations that staff were not providing proper medication assistance, shower assistance, and food service to a resident in care.

The investigation substantiated the allegation that staff failed to provide proper medication assistance to a resident, with multiple missed doses documented over a three-month period. Allegations regarding shower assistance and food service were unsubstantiated due to insufficient evidence.

The complaint investigation was substantiated for medication assistance failure but unsubstantiated for shower assistance and food service allegations. The preponderance of evidence standard was met for the medication allegation.

The visit was an unannounced case management visit to deliver amended complaint findings for Complaint Control # 22-AS-20250121161311.

The Licensing Program Analyst delivered an amended report to the Culinary Services Director and discussed the amended findings. An exit interview was conducted and a copy of the report and amended findings were provided to the facility.

The visit was related to amended complaint findings for Complaint Control # 22-AS-20250121161311.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on January 21, 2025, alleging that a resident sustained a severe burn as a result of neglect, and other allegations regarding medication administration and room cleanliness.

The investigation substantiated the allegation that Resident 1 sustained a severe burn due to neglect, confirmed by interviews, photographic evidence, and medical reports. The allegations that staff did not administer medications as prescribed and did not ensure the resident's room was cleaned were found to be unsubstantiated.

The complaint investigation was substantiated for the allegation that Resident 1 sustained a severe burn as a result of neglect. The other allegations regarding medication administration and room cleanliness were unsubstantiated.

An unannounced visit was conducted in conjunction with a complaint investigation for complaint control # 22-AS-20231117101241.

A deficiency was cited due to the facility's inability to locate Medication Administration Records from 2023, violating California Code of Regulations Title 22.

Complaint investigation for complaint control # 22-AS-20231117101241. Deficiency cited based on missing Medication Administration Records from 2023.

An unannounced complaint investigation visit was conducted following a complaint received on 2023-11-17 regarding multiple allegations about medication distribution, medical care, dietary needs, record keeping, and assistance with showering at the facility.

The investigation included interviews with residents and staff and review of pertinent documents. All allegations were determined to be unsubstantiated based on interviews and document reviews indicating that medications were distributed and taken as prescribed, medical care was performed by skilled professionals, dietary needs were met, records were current, and residents received shower assistance as needed.

The complaint included allegations that staff did not distribute residents' medications as prescribed, did not ensure residents took medications as prescribed, did not ensure skilled professionals performed medical care, did not meet residents' dietary needs, did not maintain current records, and did not assist residents with showering. The investigation found these allegations to be unsubstantiated.

Unannounced complaint investigation visit conducted due to allegations including staff authorizing medical decisions without proper consent, resident injury from a fall, failure to seek timely medical attention, and inadequate supervision.

The investigation found no corroborating evidence to support the allegations. Facility documentation and interviews indicated the resident was independent in many activities, no history or documentation of falls or hospitalizations was found, and staffing levels were adequate. The allegations were deemed unsubstantiated due to lack of preponderance of evidence.

Allegations included staff authorizing medical decisions without proper consent, resident sustained injury from a fall, staff did not seek timely medical attention, and inadequate supervision. The complaint was unsubstantiated based on interviews and record review.

Licensing Program Analyst Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation of the facility.

The facility was found to be in compliance with Title 22 Division 6 of the California Code of Regulations with no deficiencies cited. Observations included inspection of physical plant, fire safety equipment, medication storage, staff training, and resident care activities.

This unannounced Case Management – Other inspection was conducted to perform additional interviews related to Complaint Control No. 22-AS-20201103132810.

No deficiencies were observed during the inspection. Based on observations, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.

Inspection was conducted as a follow-up to a complaint (Complaint Control No. 22-AS-20201103132810).

This unannounced Case Management – Deficiencies inspection was conducted to issue citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20201103132810.

The inspection found that the facility permanently closed a window in Resident #1's room, interfering with the resident's comfort and enjoyment, which violated the requirement for safe, healthful, and comfortable accommodations. The facility's emergency disaster exit plan did not rely on windows for evacuation, and the deficiency posed a personal rights risk.

The visit was complaint-related, investigating allegations that a window in Resident #1's room was permanently screwed shut, affecting temperature regulation and comfort. The complaint was substantiated by observations and interviews.

This unannounced complaint investigation was conducted to investigate allegations including failure to provide treatment for a resident with stage 3 pressure and ankle injury, failure to report the injury to the resident's responsible party, denial of visitation from the responsible party, and missed medication dosages by facility staff.

The investigation substantiated that the facility failed to provide proper treatment and timely reporting for a resident's stage 3 pressure injury, denied visitation during COVID-19 lockdown beyond guidelines, and missed multiple medication dosages leading to potential health risks. Other allegations such as failure to call 911, overmedication, falsified care plan documentation, and unlawful increase in care cost were unsubstantiated.

The complaint investigation was substantiated for allegations related to failure to provide treatment for a stage 3 pressure injury, failure to timely notify the resident's responsible party, denial of visitation during COVID-19 lockdown, and missed medication dosages. Other allegations including failure to call 911, overmedication, falsified care plan documentation, and unlawful increase in care cost were unsubstantiated.

An unannounced complaint investigation visit was conducted to investigate the allegation that the facility does not have adequate staffing to meet the resident's needs.

The investigation included interviews, facility tour observations, and documentation review. The allegation was found to be unsubstantiated due to insufficient evidence to prove or refute the claim. Staffing was reported as adequate at the time of the visit, though some interviewees noted staffing challenges during the COVID-19 pandemic.

The complaint alleged inadequate staffing to meet resident needs. The investigation found no preponderance of evidence to substantiate the allegation, deeming it unsubstantiated.

An unannounced complaint investigation visit was conducted to investigate allegations that staff were not providing adequate care and supervision to residents.

The investigation included interviews with staff and residents, and review of documentation and staffing schedules. The allegation was deemed unsubstantiated due to insufficient evidence to prove or refute the claim, with most interviewees indicating adequate care and supervision was provided.

The complaint alleged inadequate care and supervision by staff. The investigation found staffing challenges during the COVID-19 pandemic but current staffing levels were adequate. The allegation was unsubstantiated due to lack of preponderance of evidence.

The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff were not meeting residents' needs due to lack of staff.

The investigation included interviews, review of resident records, and scheduling records from February to June 2020. The Department was unable to ascertain if the allegations occurred as reported due to lack of preponderance of evidence, and therefore the allegations were deemed unsubstantiated.

The complaint alleged that staff were not meeting residents' needs due to lack of staff. The complaint was found to be unsubstantiated due to insufficient evidence to prove or refute the allegation.

This unannounced Case Management – Incident inspection was conducted for a health and safety check and to follow up on a self-reported incident involving Resident #1 who left the facility unassisted on 10/20/2023.

The inspection found no immediate health and safety issues with the facility or Resident #1 during the visit. However, a deficiency was cited for inadequate supervision when Resident #1 left the facility unassisted, posing an immediate safety risk. The facility has since implemented motion alarms, updated resident supervision lists, and conducted staff training.

The visit was complaint-related, triggered by a self-reported incident received on 10/25/2023 regarding Resident #1 leaving the facility unassisted on 10/20/2023. The complaint was investigated and substantiated by the cited deficiency.

An unannounced complaint investigation was conducted based on allegations including lack of a facility emergency disaster plan, residents sustaining pressure injuries due to neglect, unmet dietary needs, staffing shortages, bruises on residents, and lack of required staff training.

The investigation found the allegation regarding the emergency disaster plan to be unfounded. Allegations related to pressure injuries, dietary needs, staffing shortages, and bruises were deemed unsubstantiated due to insufficient evidence. However, the allegation that facility staff lacked required training was substantiated, with seven out of seven staff lacking evidence of required annual training.

The complaint investigation was initiated due to multiple allegations: lack of a facility emergency disaster plan, residents sustaining pressure injuries due to neglect, unmet dietary needs, staffing shortages, bruises on residents, and lack of required staff training. The emergency disaster plan allegation was unfounded. The allegations about pressure injuries, dietary needs, staffing, and bruises were unsubstantiated. The allegation regarding lack of staff training was substantiated.

An unannounced complaint investigation visit was conducted to investigate the allegation that the facility did not ensure that a resident received prescribed medication.

After review of medication administration records, staff interviews, and observations, the allegation was found to be unsubstantiated. All treatments appeared to have been administered and documented accurately, with no preponderance of evidence to prove or refute the alleged violation.

The complaint alleged that the facility did not ensure that a resident received prescribed medication. The investigation included record reviews, staff interviews, and a tour of the memory care unit. The allegation was deemed unsubstantiated.

An unannounced visit was conducted for the purpose of a required annual inspection of the facility.

The facility was observed to be clean and sanitary with all resident rooms containing required elements. No deficiencies were noted during the visit.

An unannounced complaint investigation visit was conducted in response to allegations including insufficient staffing to meet resident needs, staff not meeting residents' toileting needs, unsafe environment for residents, and residents not being served nutritious meals.

Based on interviews with residents and staff, review of documentation, and observations, the allegations were determined to be unfounded. Most residents and staff reported that resident needs were met, the environment was safe, and food quality was acceptable. The complaint was found to be without reasonable basis.

The complaint investigation was unannounced and based on multiple allegations related to staffing, resident care, safety, and nutrition. The investigation included interviews with residents and staff, review of staff schedules, staffing agency invoices, and menus. The complaint was determined to be unfounded.

Unannounced case management visit to follow up on an incident report dated 04/20/2022 regarding a resident's hospitalization and subsequent passing.

No deficiencies were noted during the visit. The Licensing Program Analyst reviewed relevant documents and conducted an exit interview.