Crown Cove

Allegation investigated: Resident left in soiled urine and feces. Pests crawling on resident. Staff not keeping facility free from pests.

On January 30, 2026, Licensing Program Analyst (LPA) Jessica Cho made an unannounced subsequent visit for the purpose of continuing the investigation into the above allegations. LPA was greeted by the receptionist and was escorted into the private conference room. Wellness Director Michelle Angcaco and Executive Director Janette Hill later arrived on premise and remained at the facility to assist with the investigation. The investigation is as follows: On September 10, 2021, the Department received the complaint initiated by LPA Sean Haddad on September 16, 2021. During the course of the investigation, LPA Haddad toured the faciltiy and inspected eight resident units. Six staff, six residents, and one witness interviews were conducted, and the following documentation were obtained for review: Resident/Personnel Rosters, Identification and Emergency Information concerning Resident #1 (R1), Death Report for R1, Needs and Services Plan, Caregiver Schedule Report, pest control invoice statthe state’s words, verbatim · CDSS document, Jan 30, 2026 · control 22-AS-20210910090047

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff are not providing proper medication assistance to resident in care.

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude investigation into the above identified complaint allegation. LPA spoke with Janette Hill, Executive Director Executive Director, and explained the purpose of the visit. Findings are based upon this investigation which included tour of the facility, facility file review, resident file review, copies or perteinent documents and interviews conducted. It is alleged staff are not providing proper medication assistance to resident (R1) in care. Interview with 2 of 2 staff stated there had been issues with medication and that as of November 30, 2022, they were made aware that there was medication that was not being administered. Records revealed in review of Continued on LIC9099-C Substantiatedthe state’s words, verbatim · CDSS document, Oct 7, 2025 · control 22-AS-20221123081721

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Resident sustained a severe burn as a result of neglect

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility and explained the reason for the visit. The Department received a complaint on January 23, 2025, and the initial 10-day visit was conducted that same day by LPA Mendivil. LPA Mendivil obtained copies of documents including physician’s reports, needs and services, medication records and admission agreements. Regarding the allegation resident sustained a severe burn as a result of neglect, the investigation revealed the following: It was alleged that Resident 1 (R1) had sustained a severe burn as a result of neglect. Based on physician’s report dated December 23, 2023, R1 has a history of skin breakdown and was listed as able to feed themselves. Per review of Senior Living Standard Level of Care and Services Plan dated September 11, 2024, it was reported that R1 needed assistance with eating. Review of emails between thethe state’s words, verbatim · CDSS document, May 30, 2025 · control 22-AS-20250121161311

Allegation investigated: Staff is authorizing medical decisions without proper consent Resident sustained an injury from a fall while in care Staff did not seek timely medical attention for a resident Staff did not provide adequate supervision to a resident

Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced complaint visit to continue the investigation into the above allegations. LPAs were greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPAs toured the facility and interviewed staff and residents as well as reviewed and obtained pertinent documentation such as care plans. Regarding the allegations that staff is authorizing medical decisions without proper consent, resident sustained an injury from a fall while in care, staff did not seek timely medical attention for a resident and staff did not provide adequate supervision to a resident, the investigation revealed the following: Per facility care plan dated 01/29/2021, Resident 1 (R1) requires assistance with showers and clothing but is independent with toileting, eating, grooming and medications. Resident does not require assurance checks and is able to leave the facilitthe state’s words, verbatim · CDSS document, Jan 27, 2025 · control 22-AS-20211220140822

Allegation investigated: Staff do not distribute residents' medications as prescribed Staff do not ensure that a resident takes medication as prescribed Licensee does not ensure that a skilled professional performs residents' medical care Staff did not ensure that a resident's dietary needs were met Staff do not maintain residents' records current Staff do not assist a resident with showering

On this day, Licensing Program Analysts ( LPAs) Andrea Mendivil and Kimberly Lyman made an unannounced visit to continue complaint investigation. LPAs Mendivil and Lyman were greeted and granted entry into the facility and explained the reason for the visit. The Department received a complaint on 11/17/2023 and LPA Mendivil conducted the initial visit on 11/27/2023. LPA Mendivil interviewed staff and residents and obtained copies of pertinent documents such as physicians reports, assessments and dinning menus. Regarding the allegations staff do not distribute residents' medications as prescribed, staff do not ensure that a resident takes medication as prescribed, licensee does not ensure that a skilled professional performs residents' medical care, staff did not ensure that a residents dietary needs were met, staff do not maintain residents' records current, staff do not assist a resident with showering, the investigation revealed the following: Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 27, 2025 · control 22-AS-20231117101241

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility did not provide treatment to resident with stage 3 pressure and ankle injury Facility did not report pressure/ankle injury to resident's responsible party Resident denied visitation from responsible party Facility staff missed dosages of medication

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPA met with Administrator (AD) Janette Hill, discussed the purpose of the inspection, and explained the allegations. The investigation into the allegations that the facility did not provide treatment to resident with stage 3 pressure and ankle injury, the facility did not report pressure/ankle injury to resident's responsible party, a resident denied visitation from responsible party, and facility staff missed dosages of medication revealed the following: During the course of the investigation, LPA interviewed former administrators, staff, and a witness, and obtained and reviewed copies of the resident roster, staff roster, Photographs of Resident #1 (R1), R1’s Home Health Medical Records dated December 29, 2020, R1’s Home Health Medical Records dated January 21, 2021, R1’s Physician’the state’s words, verbatim · CDSS document, Jul 15, 2024 · control 22-AS-20201103132810

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: -Facility does not have adequate staffing to meet the resident's needs.

On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit for the purpose to conduct additional interviews, review documentation and conclude findings for complaint allegation listed above. LPA Quiroz was greeted and granted entry by front desk concierge. LPA met with Business Office Manager (BOM) Gerardo Garibay and Executive Director (ED) Carrie Galloway and explained the nature of the visit. The 10 day visit was conducted on 8/31/2020 by LPA Patricia Velazquez. During the course of the investigation, LPAs conducted interviews with interviewees consisting of staff and Residents, conducted facility tour observations and conducted documentation review but not limited to resident roster, staff roster, physician report, identification form, needs and services plan and staff schedules. Regarding the allegation "Facility does not have adequate staffing to meet the resident's needs," the investigation revealed the following: Title 22 regulation states: Facthe state’s words, verbatim · CDSS document, Dec 12, 2023 · control 22-AS-20200826161002

Allegation investigated: -Staff is not providing adequate care and supervision to the residents

On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit for the purpose to conduct additional interviews, review documentation and conclude findings for complaint allegations listed above. LPA Quiroz was greeted and granted entry by front desk concierge. LPA met with Business Office Manager (BOM) Gerardo Garibay and Executive Director (ED) Carrie Galloway and explained the nature of the visit. The 10 day visit was conducted on 11/18/2021 by LPA Quiroz. During the course of the investigation, LPAs conducted interviews with interviewees consisting of staff and Residents. LPA Quiroz also conducted documentation review but not limited to resident roster, staff roster, physician report, identification form, needs and services plan and staff schedules. Regarding the allegation " Staff is not providing adequate care and supervision to the residents," the investigation revealed the following: Title 22 regulation states: Facility personnel shall at all timesthe state’s words, verbatim · CDSS document, Dec 12, 2023 · control 22-AS-20211109133758

Allegation investigated: Staff are not meeting residents needs due to lack of staff

This unannounced visit conducted by Ruth Martinez, Licensing Program Analyst (LPA), is being conducted to conclude this agency’s investigation into the complaint allegation mentioned above. LPA arrived at facility was greeted by staff and granted entry. LPA met with Carrie Galloway, Executive Director and explained the nature of the visit. During the course of this investigation interviews were conducted, a review of resident records was completed, and copy of pertinent documents obtained. It is alleged that staff are not meeting residents needs due to lack of staff. Title 22 regulation states: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Scheduling records from February 2020 to June 2020 revel that facility has three scheduled shifts morning 6:30am -3:00pm, afternoon shift 2:30pm to 11:00pm, and NOC shift 10:30pm – 2:00am and facility had a nursing schedule Continued on LIC9099-c Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 2, 2023 · control 22-AS-20200731152125

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Licensee does not have a facility emergency disaster plan

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA interviewed staff and reviewed and obtained pertinent documentation such as emergency disaster plan. Regarding the allegation that licensee does not have a facility emergency disaster plan, the investigation revealed the following: LPA observed and reviewed the facility emergency disaster plan outlining all required emergency directives. Therefore the allegation is deemed UNFOUNDED, meaning the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was provided to facility representative. Unfoundedthe state’s words, verbatim · CDSS document, Oct 18, 2023 · control 22-AS-20230609081714