Inspection Reports for Crown Cove
3901 East Coast Hwy, Corona Del Mar, CA 92625, United States, CA, 92625
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, with several complaint investigations determined to be unsubstantiated. However, some reports cited deficiencies related primarily to medication assistance, resident care, and staff training. The most serious issues included a substantiated neglect case in May 2025 where a resident sustained a severe burn, and multiple missed medication doses documented in October 2025. The most recent report from October 7, 2025, had one deficiency for missed medication doses but no severe enforcement actions or fines were listed in the available reports. The facility’s record shows some improvement in areas like record keeping and supervision, though medication management and resident care remain areas needing attention.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
2.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
38% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
71% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 69
Capacity: 97
Deficiencies: 1
Date: Oct 7, 2025
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to assist residents with self-administered medications as needed, resulting in missed doses for a resident over multiple days.
Report Facts
Medications missed: 9
Capacity: 97
Census: 69
Plan of Correction Due Date: Oct 21, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Armando J Lucero | Licensing Program Manager | Oversaw the complaint investigation report. |
| Janette Hill | Executive Director | Facility representative interviewed during the investigation. |
Inspection Report
Census: 69
Capacity: 97
Deficiencies: 0
Date: Jul 3, 2025
Visit Reason
The visit was an unannounced case management visit to deliver amended complaint findings for Complaint Control # 22-AS-20250121161311.
Complaint Details
The visit was related to amended complaint findings for Complaint Control # 22-AS-20250121161311.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kasan Soewono | Culinary Services Director | Met with during the visit and recipient of the amended complaint findings report. |
| Andrea Mendivil | Licensing Program Analyst | Conducted the unannounced visit and delivered the amended complaint findings. |
| Janette Hill | Administrator | Named as facility administrator. |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager overseeing the visit. |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 97
Deficiencies: 1
Date: May 30, 2025
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Basic services requirement was not met as licensee did not ensure Resident 1 was assisted properly with food services, resulting in the resident spilling coffee or hot liquids on themselves causing blisters.
Report Facts
Capacity: 97
Census: 68
Deficiencies cited: 1
Plan of Correction Due Date: Jun 2, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janette Hill | Executive Director | Met with during inspection and named as facility administrator |
| Andrea Mendivil | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Alisa Ortiz | Licensing Program Manager | Oversaw the complaint investigation |
| Kasan Soewono | Culinary Service Director | Participated in exit interview |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 97
Deficiencies: 1
Date: Jan 27, 2025
Visit Reason
An unannounced visit was conducted in conjunction with a complaint investigation for complaint control # 22-AS-20231117101241.
Complaint Details
Complaint investigation for complaint control # 22-AS-20231117101241. Deficiency cited based on missing Medication Administration Records from 2023.
Findings
A deficiency was cited due to the facility's inability to locate Medication Administration Records from 2023, violating California Code of Regulations Title 22.
Deficiencies (1)
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 evidenced by facility did not obtain Medication Administration Records from 2023.
Report Facts
Capacity: 97
Census: 59
Plan of Correction Due Date: Due date for correction is 02/02/2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janette Hill | Executive Director | Met during inspection and discussed missing Medication Administration Records |
| Andrea Mendivil | Licensing Program Analyst | Conducted the inspection and cited the deficiency |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 97
Deficiencies: 0
Date: Jan 27, 2025
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Facility capacity: 97
Census: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Mendivil | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Kimberly Lyman | Licensing Program Analyst | Assisted in the complaint investigation visit |
| Janette Hill | Executive Director | Met with investigators during the visit |
| Kameshi Taylor | Administrator | Facility administrator named in the report |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 97
Deficiencies: 0
Date: Jan 27, 2025
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 97
Census: 59
Staffing levels: 3
Staffing levels: 2
Staffing levels: 1
Residents interviewed: 5
Staff interviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted complaint investigation |
| Andrea Mendivil | Licensing Program Analyst | Conducted complaint investigation |
| Kameshi Taylor | Administrator | Facility administrator at time of complaint |
| Janette Hill | Met with during investigation | |
| Alisa Ortiz | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Annual Inspection
Census: 67
Capacity: 97
Deficiencies: 0
Date: Nov 20, 2024
Visit Reason
Licensing Program Analyst Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation of the facility.
Findings
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.
Report Facts
Fire extinguisher service date: Aug 7, 2024
Smoke detector test date: Apr 5, 2023
Fire drill date: Nov 13, 2024
Administrator certificate expiration: Jul 13, 2026
Resident records reviewed: 6
Staff training records reviewed: 5
Hot water temperature range: Hot water temperatures measured between 109.4 and 116.7 degrees Fahrenheit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janette Hill | Executive Director | Met with Licensing Program Analyst during inspection and participated in exit interview. |
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the unannounced annual inspection visit. |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 67
Capacity: 97
Deficiencies: 0
Date: Jul 30, 2024
Visit Reason
This unannounced Case Management – Other inspection was conducted to perform additional interviews related to Complaint Control No. 22-AS-20201103132810.
Complaint Details
Inspection was conducted as a follow-up to a complaint (Complaint Control No. 22-AS-20201103132810).
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janette Hill | Administrator | Met with Licensing Program Analyst during inspection. |
| Sean Haddad | Licensing Program Analyst | Conducted the inspection and interviews. |
| Armando J Lucero | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 97
Deficiencies: 1
Date: Jul 15, 2024
Visit Reason
This unannounced Case Management – Deficiencies inspection was conducted to issue citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20201103132810.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure Resident #1 had safe, healthful, and comfortable accommodations by permanently closing their window.
Report Facts
Capacity: 97
Census: 68
Plan of Correction Due Date: Jul 29, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sean Haddad | Licensing Program Analyst | Conducted the inspection and issued citations |
| Janette Hill | Administrator | Met with Licensing Program Analyst during inspection |
| Armando J Lucero | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 97
Deficiencies: 4
Date: Jul 15, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (4)
The licensee did not ensure R1, who had known skin issues, received proper assistance and medical care resulting in R1 developing an unstageable wound.
The licensee did not ensure R1’s worsening skin condition was noted and brought to the attention of their responsible party.
The 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.
The licensee did not ensure R1 received multiple medications as prescribed.
Report Facts
Facility capacity: 97
Census: 68
Deficiency count: 4
Plan of Correction due date: Jul 16, 2024
Plan of Correction due date: Jul 29, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sean Haddad | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Armando J Lucero | Licensing Program Manager | Oversaw the complaint investigation |
| Janette Hill | Administrator | Facility administrator met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 97
Deficiencies: 0
Date: Dec 12, 2023
Visit Reason
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.
Complaint Details
The complaint alleged inadequate staffing to meet resident needs. The investigation found no preponderance of evidence to substantiate the allegation, deeming it unsubstantiated.
Findings
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.
Report Facts
Facility census at time of complaint: 65
Current staffing levels: 3
Current staffing levels: 2
Current staffing levels: 1
Total licensed capacity: 97
Current census: 63
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosie Quiroz | Licensing Program Analyst | Conducted the complaint investigation visit |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Carrie Galloway | Executive Director | Met with during investigation and provided staffing information |
| Gerardo Garibay | Business Office Manager | Met with during investigation |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 97
Deficiencies: 0
Date: Dec 12, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff were not providing adequate care and supervision to residents.
Complaint Details
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.
Findings
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.
Report Facts
Facility capacity: 97
Census: 63
Complaint receipt date: Nov 9, 2021
Staffing during complaint timeframe: 33
Interviewees: 15
Interviewees indicating adequate care: 14
Interviewees with no knowledge of facility during complaint timeframe: 8
Interviewees indicating staffing challenges during COVID-19: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosie Quiroz | Licensing Program Analyst | Conducted the complaint investigation visit |
| Alisa Ortiz | Licensing Program Manager | Oversaw the complaint investigation |
| Carrie Galloway | Executive Director | Facility representative met during investigation and exit interview |
| Gerardo Garibay | Business Office Manager | Facility representative met during investigation |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 97
Deficiencies: 0
Date: Nov 2, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff were not meeting residents' needs due to lack of staff.
Complaint Details
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.
Findings
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.
Report Facts
Facility census at time of complaint: 69
Scheduled nursing shifts: 3
Nurses on morning shift: 2
Nurses on afternoon shift: 2
Nurses on night shift: 2
Caregivers on morning shift: 4
Caregivers on afternoon shift: 4
Care staff on morning shift: 6
Care staff on afternoon shift: 3
Care staff on night shift: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the complaint investigation |
| Armando J Lucero | Licensing Program Manager | Named in report as Licensing Program Manager |
| Carrie Galloway | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 97
Deficiencies: 1
Date: Oct 30, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Licensee did not provide adequate supervision to Resident #1 when they left the facility without assistance, posing an immediate safety risk to persons in care.
Report Facts
Deficiency count: 1
Plan of Correction Due Date: Oct 31, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sean Haddad | Licensing Program Analyst | Conducted the inspection and authored the report |
| Armando J Lucero | Licensing Program Manager | Supervisor overseeing the inspection |
| Carrie Galloway | Administrator | Facility administrator interviewed during inspection |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 97
Deficiencies: 1
Date: Oct 18, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Licensees shall maintain in the personnel records verification of required staff training and orientation.
Report Facts
Capacity: 97
Census: 63
Staff training records reviewed: 7
Fire drill training dates observed: 2
Plan of Correction Due Date: Nov 1, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Kameshi Taylor | Administrator | Facility administrator named in the report |
| Carrie Galloway | Facility representative met during the investigation |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 97
Deficiencies: 0
Date: May 30, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate the allegation that the facility did not ensure that a resident received prescribed medication.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 97
Census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyre Richards | Assisted Living Program Director | Met with during the investigation and involved in locating absent documentation |
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Carrie Galloway | Executive Director | Met with during the investigation |
Inspection Report
Annual Inspection
Census: 31
Capacity: 97
Deficiencies: 0
Date: Sep 15, 2022
Visit Reason
An unannounced visit was conducted for the purpose of a required annual inspection of the facility.
Findings
The facility was observed to be clean and sanitary with all resident rooms containing required elements. No deficiencies were noted during the visit.
Report Facts
PPE supply duration: 4
Non-perishable food supply: 7
Perishable food supply: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tonantzin Martinez | Memory Care Program Director | Met with Licensing Program Analyst during inspection |
| Tyre Richards | Assisted Living Program Director | Met with Licensing Program Analyst during inspection and toured facility |
Inspection Report
Complaint Investigation
Census: 33
Capacity: 97
Deficiencies: 0
Date: Aug 2, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Residents interviewed: 5
Staff interviewed: 6
Capacity: 97
Census: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kameshi Taylor | Executive Director | Facility representative who granted entry and participated in exit interview |
| Andrea Mendivil | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
| Alisa Ortiz | Licensing Program Manager | Manager overseeing the complaint investigation |
Inspection Report
Census: 31
Capacity: 97
Deficiencies: 0
Date: Apr 28, 2022
Visit Reason
Unannounced case management visit to follow up on an incident report dated 04/20/2022 regarding a resident's hospitalization and subsequent passing.
Findings
No deficiencies were noted during the visit. The Licensing Program Analyst reviewed relevant documents and conducted an exit interview.
Report Facts
Incident report date: Apr 20, 2022
Resident hospitalization date: Apr 5, 2022
Resident passing date: Apr 13, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kameshi Taylor | Executive Director | Met with Licensing Program Analyst during visit |
| Bernadette Sajia | Assisted Living Program Director (LVN) | Interviewed regarding resident's condition and hospital transfer |
| Andrea Mendivil | Licensing Program Analyst | Conducted the unannounced case management visit |
| Alisa Ortiz | Licensing Program Manager | Named in report header |
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