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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006198
Report Date: 02/24/2023
Date Signed: 02/24/2023 04:13:20 PM


Document Has Been Signed on 02/24/2023 04:13 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:CRESTAVILLAFACILITY NUMBER:
306006198
ADMINISTRATOR:STEPHEN W PRATTFACILITY TYPE:
740
ADDRESS:30111 NIGUEL RDTELEPHONE:
(760) 804-5900
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:250CENSUS: 144DATE:
02/24/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Michael OsterbauerTIME COMPLETED:
04:25 PM
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of a health and safety check and to follow up on a report that Resident #1 (R1) had recently passed away. LPA met with Administrator (AD) Michael Osterbauer and explained the purpose of the inspection.

During the inspection, LPA and AD toured the facility and inspected R1’s room. LPA conducted a health and safety check on R1’s spouse and confirmed they were doing well and observed no health and safety issues. LPA observed the facility to be clean and organized, and found no health and safety issues. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. LPA observed the electricity and water were running and the facility had soap and paper towels. LPA interviewed R1’s spouse and confirmed the details as reported by the facility. LPA interviewed AD regarding R1 and requested and reviewed copies of R1’s resident file.

Facility representative was advised that at this time further investigation is required. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
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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