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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005326
Report Date: 04/28/2022
Date Signed: 04/28/2022 04:49:05 PM


Document Has Been Signed on 04/28/2022 04:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:CRESTAVILLA SENIOR LIVINGFACILITY NUMBER:
306005326
ADMINISTRATOR:KEYS, BRIANFACILITY TYPE:
740
ADDRESS:30111 NIGUEL RDTELEPHONE:
(949) 345-1606
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:250CENSUS: 187DATE:
04/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Brian KeysTIME COMPLETED:
05:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a case management visit. LPA was screened for symptoms of Covid-19 and granted entry. LPA met with Executive Director Brian Keys. LPA explained the reason for the visit. The Agency received an unusual incident report on 4/27/2022 dated 4/26/2022. Based on the report and an interview with the Executive Director, Resident 1 (R1) eloped from the facility on 4/26/2022 at 10:34 am. R1 has been diagnosed with Dementia. R1 eloped from the facility through an exit gate located in the garden area of the memory care unit. The staff notified the Orange County Sheriff and the responsible party. The staff immediately began searching the facility and surrounding area for the resident. The Orange County Sheriff located the resident 60 minutes later. Paramedics evaluated R1 and checked for injuries. No injuries noted and R1 was returned to the facility at 12:00pm. R1 is currently at the facility and no new issues reported. R1 has been placed on updated status checks. Staff have been retrained on elopement behaviors and procedures. LPA was provided with R1's physician's report. Violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report along with citations and Appeal Rights was provided to the Executive Director.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/28/2022 04:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: CRESTAVILLA SENIOR LIVING
FACILITY NUMBER: 306005326

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2022
Section Cited

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Care of Person's With dementia - Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents and to escort residents who leave the facility.
This requirement was not met as evidenced by:
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R1 has been diagnosed with Dementia and wandered from the Community without staff supervision and was not checked out of the community with their responsible party.
This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
LIC809 (FAS) - (06/04)
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