306006198-12-2-2022-22-AS-JALE-CLQTXD-20221202140657

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006198
Report Date: 12/02/2022
Date Signed: 12/02/2022 02:07:13 PM

Document Has Been Signed on 12/02/2022 02:07 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		FACILITY NUMBER:	306006198
ADMINISTRATOR:	WILLIAMS, CYNTHIA		FACILITY TYPE:	740
ADDRESS:	30111 NIGUEL RD		TELEPHONE:	(760) 804-5900
CITY:	LAGUNA NIGUEL	STATE: CA	ZIP CODE:	92677
CAPACITY:	250	CENSUS: 153	DATE:	12/02/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Cynthia Williams		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Joseph Alejandre made an announced visit to conduct the pre-licensing inspection. LPA was screened for symptoms of Covid-19 and granted entry. LPA met with Administrator Cynthia Williams and Facilities Director David Deger and General Manager Michael Osterbauer. LPA explained the reason for the visit. An application to operate a Residential Care Facility for the Elderly (RCFE) for a capacity of 240 non-ambulatory residents and 10 bedridden residents for a total capacity of 250 residents and hospice waiver for 20 was submitted to Community Care Licensing (CCL), the application is dated 8/03/2022. Structure: The facility is a three story building with 211 resident rooms. There is fountain near the entrance of the facility in the small traffic circle used for resident drop off and pick up. Facility has outside patios for outdoor activities and dining. Facility telephone phone number is 949-272-9772. LPA observed the See Something, Say Something poster (PUB 475) in the main entrance of the facility. LPA observed the Ombudsman poster with address and phone number of the local Ombudsman posted in the mail room on the first floor. Facility fire clearance is approved for delayed egress exits. Facility has delayed egress exit doors in memory care. Resident rooms Resident rooms are private rooms which have a closet, bathroom and small kitchen. Residents move in with their own furnishings but the facility will provide the required furnishings, bed, night stand, lamp, chair and a chest of drawers if residents require it. Signal system The signal system operates from each resident room and common bathrooms. The signal system is operational and meets the regulatory requirements.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022

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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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	FACILITY NUMBER: 306006198
	VISIT DATE: 12/02/2022

NARRATIVE

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Bathrooms:
All bathrooms have working plumbing. LPA observed the common bathrooms to be clean and operational. LPA measured the hot water in room number 142 to be 114.2 degrees Fahrenheit and the hot water in room 366 to be 108.6 degrees Fahrenheit.

Linens & Hygiene Supplies:
Adequate supply of linen and cleaning supplies stored in the supply closets.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one month prior and listed for food served for one month. Emergency food and water supply is stored in a storage room.

Food Service:
LPA observed the kitchen is clean and organized. The freezer and refrigerator are at the required temperatures. LPA observed a 2 day perishable food supply and a 7 day non-perishable food supply on hand in the kitchen pantry.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors are operational. The fire sprinkler system is maintained by a third party vendor.

Toxins:
All toxic chemicals, cleaning solutions, laundry toxins and disinfectants used by the facility are stored in locked storage rooms/closets and inaccessible to residents.

Medications, First-Aid Kit & Book:
Medication is stored in the locked medication room on the first floor. There is a first aid kit in the medication room and they are located throughout the facility.

Resident & Staff Files:
Records will be kept secured in the facility offices.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022

LIC809 (FAS) - (06/04)

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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	FACILITY NUMBER: 306006198
	VISIT DATE: 12/02/2022

NARRATIVE

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Pool/Jacuzzi & Pets:
Facility pool is fenced and secured. Residents are allowed to keep small pets in their room as agreed upon in their admission agreement.

Fire Extinguisher:
All facility fire extinguishers are fully charged and located throughout the facility. LPA observed emergency chair lifts at each stairwell.

Reading Material, Games, Equipment & Materials:
The facility has numerous supplies for activities including supplies for arts and crafts, board games, books and a large TV in the theater room. The activity calendar is posted on each floor of the facility for the current month.

Fire clearance:
Was approved by Orange County Fire Authority inspector Nathan Bobbitt on 7/11/2022. Fire clearance is approved for 240 non-ambulatory residents and 10 bedridden residents for a total capacity of 250. Delayed egress exits are approved.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance and reporting requirements.

The Administrator was notified that the final application approval will be issued by the Centralized Applications Bureau (CAB) in Sacramento. LPA informed the Administrator that once the facility is licensed a post licensing visit will be conducted within 90 days of licensure. LPA did not observe any obstacles or hazards inside or outside of the facility. No deficiencies observed during the visit. The facility meets Title 22 requirements and is ready to be licensed. Exit interview was conducted and a copy of this report was provided to the Administrator.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022

LIC809 (FAS) - (06/04)

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