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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005326
Report Date: 07/26/2022
Date Signed: 07/26/2022 11:51:30 AM


Document Has Been Signed on 07/26/2022 11:51 AM - 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: 188DATE:
07/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Stacy CastoTIME COMPLETED:
11:59 AM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was greeted and granted entry by staff. LPA met with Stacy Casto, Regional Director of Nursing. LPA explained the reason for the the visit. Facility is a three story building with memory care on the first floor. LPA and staff toured the facility. LPA observed one central entry point with a visitor check in area. LPA observed all staff were wearing masks. LPA and staff toured the kitchen. LPA observed a 2 day perishable and 7 day non-perishable food supply on hand in the kitchen. LPA observed the kitchen is clean and organized. LPA observed the emergency food and water supply on hand in the kitchen store room. LPA observed all of the fireplaces on the first floor are screened. LPA observed the PUB 475 poster (See Something, Say Something poster) posted in the entrance way of the facility. LPA and staff toured all 3 floors of the facility. No obstacles or hazards observed inside or outside of the facility. LPA observed all fire extinguishers are fully charged. LPA observed an emergency chair lift at each stairwell. LPA observed a 30 day supply of PPE stored at the facility. LPA discussed continued Covid-19 mitigation procedures with staff and reporting requirements. No deficiencies observed during the visit. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
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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