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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006198
Report Date: 09/01/2022
Date Signed: 09/01/2022 09:02:31 AM


Document Has Been Signed on 09/01/2022 09:02 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:CRESTAVILLAFACILITY NUMBER:
306006198
ADMINISTRATOR:WILLIAMS, CYNTHIAFACILITY TYPE:
740
ADDRESS:30111 NIGUEL RDTELEPHONE:
(760) 804-5900
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:250CENSUS: DATE:
09/01/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Cynthia WilliamsTIME COMPLETED:
09:01 AM
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Component II completion: Successful

Facility Type: RCFE
Application Type: CHOW
Capacity: 250
Census (if any clients in care): 175
COMP II Participants: Cynthia Williams (applicant/licensee rep./administrator)
Interview Method: Telephone interview

On 09/01/2022, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISOR'S NAME: Mirella QuarantaTELEPHONE: (916) 657-2025
LICENSING EVALUATOR NAME: Susan NguyenTELEPHONE: (916) 657-2600
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
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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