306005326-7-22-2025-22-AS-MSEY-DJTT2U-20250722142118

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005326
Report Date: 07/22/2025
Date Signed: 07/22/2025 08:50:57 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/14/2022 and conducted by Evaluator Donna Gurriere

COMPLAINT CONTROL NUMBER: 22-AS-20220614095837

FACILITY NAME:	CRESTAVILLA SENIOR LIVING		FACILITY NUMBER:	306005326
ADMINISTRATOR:	KEYS, BRIAN		FACILITY TYPE:	740
ADDRESS:	30111 NIGUEL RD		TELEPHONE:	(949) 345-1606
CITY:	LAGUNA NIGUEL	STATE: CA	ZIP CODE:	92677
CAPACITY:	0	CENSUS:	DATE:	07/22/2025
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Not Available		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Facility staff did not administer resident's medication as prescribed.
Lack of care and supervision resulted in resident suffering multiple falls.
Staff are not properly trained to care for residents and to administer medications.
Staff not keeping resident's room clean.
Facility did not have hot water.

INVESTIGATION FINDINGS:

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On 07/21/25 Donna Gurriere, Licensing Program Analyst (LPA) attempted to contact the licensee; however, the facility had a change of ownership and was closed on 06/29/23. The purpose of the telephone call was to discuss a complaint that was received on 06/14/22.

Facility staff did not administer resident's medication as prescribed.

There was a change in ownership and the new facility name is Crestavilla. The current administrator was contacted, and she advised that she was not working in the administrator position during the time of the complaint and that she is not familiar with the allegations. The administrator reported that there are no staff persons working at the facility that were working in 2022.

continued

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20220614095837

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CRESTAVILLA SENIOR LIVING	FACILITY NUMBER: 306005326
	VISIT DATE: 07/22/2025

NARRATIVE

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Several agencies or persons were contacted to include the Director for the Long-term Care Ombudsman’s office, and she reported that their agency does not have any open complaints from 2022.

There is not enough information to support the allegation mentioned above; therefore, in this matter the allegation is unsubstantiated.

Lack of care and supervision resulted in resident suffering multiple falls.
See above mentioned documentation.

Staff are not properly trained to care for residents and to administer medications.
See above mentioned documentation.

Staff not keeping resident's room clean.
See above mentioned documentation.

Facility did not have hot water.
See above mentioned documentation.

Although the above allegations mentioned may have happened, or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the above findings are Unsubstantiated.

Donna Gurriere, Licensing Program Analyst (LPA) issued this report on 07/22/25 to follow up on unsubstantiated allegations of a complaint investigation. The facility closed on 06/29/23.

During the course of the investigation, the Department was unable to obtain records, interview notes, or other supporting documents related to this complaint. Due to the lack of documentation and the significant passage of time, there is insufficient evidence, and the allegations are Unsubstantiated.

A copy of this report will be sent via certified mail to the last known address of the licensee. If possible, the licensee is to sign and return a copy to the Orange County Regional Office.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025

LIC9099 (FAS) - (06/04)

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