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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006198
Report Date: 08/28/2025
Date Signed: 08/28/2025 02:53:49 PM

Unfounded


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
08/26/2025 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250826093143
FACILITY NAME:CRESTAVILLAFACILITY NUMBER:
306006198
ADMINISTRATOR:MYRA ARAGONESFACILITY TYPE:
740
ADDRESS:30111 NIGUEL RDTELEPHONE:
(949) 844-5997
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:250CENSUS: 191DATE:
08/28/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Paola Carrillo, Deserie RodilloTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not get timely medical care for resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Hospitality Services Director Paolla Carrillo and Assisted Living Director Deserie Rodillo. LPA explained the reason for the visit. LPA toured the facility. LPA interviewed staff and residents. LPA requested documents such as admission agreements, physician reports, needs and care plans, medication administration records, resident progress notes, resident roster, staff roster and staff schedule. The investigation into the allegation, staff did not get timely medical care for resident revealed the following. It was reported that Resident 1 (R1) sustained an injury that required medical attention. On August 3, 2025 in the afternoon, R1 was noted to have an injury on each forearm. Resident 2 (R2) noticed the injuries and took R1 to the Wellness office. The Resident Care Coordinator (RCC) assessed R1 and determined that the only injuries were 2 skin tears, one on each forearm. The RCC administered first aid. The RCC reported that R1 reported no pain and could not remember how the injuries occurred..
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 22-AS-20250826093143
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
FACILITY NUMBER: 306006198
VISIT DATE: 08/28/2025
NARRATIVE
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 The RCC contacted R1's responsible party and primary care physician (PCP). The PCP arranged for a Home Health visit which took place on August 12, 2025. The Home Health notes show both wounds are closed with no sign of infection. The Home Health notes describe the injuries as skin tears. The RCC reported that the injuries were cleaned daily and bandaged daily. LPA interviewed R1, R1 did not recall the incident and reported they did not fall recently. LPA interviewed R2 who reported there was no blood on R1's clothing and there minimal blood on the skin tears. The RCC reported that R1 only required first aid and because no pain was reported and no other injuries were noted it wasn't necessary to call 911. The RCC reported that R1 was not nervous or displaying any signs of distress. Based on the evidence gathered the allegation, staff did not get trimly medical care for resident is deemed unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
08/26/2025 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250826093143

FACILITY NAME:CRESTAVILLAFACILITY NUMBER:
306006198
ADMINISTRATOR:MYRA ARAGONESFACILITY TYPE:
740
ADDRESS:30111 NIGUEL RDTELEPHONE:
(949) 844-5997
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:250CENSUS: DATE:
08/28/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Paola Carrillo, Deserie RodilloTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Due to lack of supervision, resident fell sustaining an injury
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Hospitality Services Director Paola Carrillo and Assisted Living Director Deserie Rodillo. LPA explained the reason for the visit. LPA and the Executive Director toured the facility. LPA interviewed staff. LPA requested documents such as admission agreements, physician reports, needs and care plans, medication administration records, resident progress notes, resident roster, staff roster and staff schedule. The investigation into the allegation, due to lack of supervision, resident fell sustaining an injury. It was reported that due to a lack of supervision R1 sustained a injury because of a fall on August 3, 2025. R1 did have 2 skin tears on their forearms. R1 could not recall how they sustained their injuries. Staff performed fisrt aid on R1 but did not witness any incidents concerning R1 and how they sustained their injuries. R2 brought R1 to the Wellness office because they saw R1's injuries but they did not see how they occured. R1 reported no pain and could not provide any details as to how they were injured. The facility does not have any indoor video survelliance. Staff interviewed were unaware of any incidents of R1 falling on August 3, 2025.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 22-AS-20250826093143
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
FACILITY NUMBER: 306006198
VISIT DATE: 08/28/2025
NARRATIVE
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No evidence was gathered to support the allegation. Therefore the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
08/26/2025 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250826093143

FACILITY NAME:CRESTAVILLAFACILITY NUMBER:
306006198
ADMINISTRATOR:MYRA ARAGONESFACILITY TYPE:
740
ADDRESS:30111 NIGUEL RDTELEPHONE:
(949) 844-5997
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:250CENSUS: DATE:
08/28/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Paola Carrillo, Deserie RodilloTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not provide an incident report to authorized representatives
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Hospitality Services Director Paola Carrillo and Assisted Living Director Deserie Rodillo. LPA explained the reason for the visit. LPA and the Executive Director toured the facility. LPA interviewed staff. LPA requested documents such as admission agreements, physician reports, needs and care plans, medication administration records, resident progress notes, resident roster, staff roster and staff schedule. The investigation into the allegation, staff did not provide an incident report to authorized representatives revealed the following. It was reported that Resident 1 (R1) suffered injuries on August 3, 2025. The Resident Care Coordinator (RCC) and Resident 2 (R2) verified that R1 did have 2 skin tears one on each forearm on August 3, 2025. The RCC reported they applied first aid and called the responsible party and the primary care physician. (PCP) for R1. R1's responsible party verified they received the call about R1 having injuries on August 3, 2025. The Assisted Living Director reported that they sent an email report to the responsible party on August 12, 2025. LPA received a copy of the email verifying the facility did provide a
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 22-AS-20250826093143
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
FACILITY NUMBER: 306006198
VISIT DATE: 08/28/2025
NARRATIVE
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a written report to the responsible party concerning R1's injuries. California Code of Regulation (CCR) Title 22, Division 6, 87211(a)(1) states, "A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below." R1 received first aid for their injuries on their forearms so this incident qualifies under CCR Title 22, Division 6 87211(a)(1)(D) which states, "Any incident which threatens the welfare, safety or health of any resident". The incident involving R1 took place on August 3, 2025 and the facility did not report the incident in writing until August 12, 2025, 9 days later. A record review of incidents reports submitted to the Agency from the facility for the month of August 2025 show the facility did not report the incident to the Agency. Based on the evidence gathered, the preponderance of evidence standard has been met, therefore the allegation is substantiated. Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations (CCR). An exit interview was conducted and a copy of the report provided along with appeal rights.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Citations on this Visit Report are Under Appeal!

Control Number 22-AS-20250826093143
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
FACILITY NUMBER: 306006198
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
09/08/2025
Section Cited
CCR
87211(a)(1)(D)
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87211(a)Each licensee shall furnish to the licensing agency ...(1)A written report shall be submitted to the licensing agency and to the person responsible within seven days... (D)Any incident which threatens the welfare, safety or health of any resident...
This requirement is not met as evidenced by:
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Licensee agrees to train staff who submit incident reports to the Agency on CCR 87211 and to provide proof of training to LPA by POC due date.
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The Licensee did not submit a written report for R1's incident that took place on August 3, 2025, to the responsible party and the Licensing Agency within seven days, which poses a potential health, safety and personal rights risk to residents.
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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.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7