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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006198
Report Date: 04/13/2023
Date Signed: 04/13/2023 01:44:20 PM


Document Has Been Signed on 04/13/2023 01:44 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: 146DATE:
04/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Michael OsterbauerTIME COMPLETED:
01:55 PM
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This unannounced inspection is being conducted by Licensing Program Analysts (LPAs) Dwayne Mason Jr. and Sean Haddad for the purpose of a health and safety check and to conclude the follow up on a report that Resident #1 (R1) had recently passed away. LPAs met with Administrator (AD) Michael Osterbauer and explained the purpose of the inspection.

During the inspection, LPAs and AD toured the facility. AD stated that R1’s spouse is doing well, the facility checks on R1’s spouse regularly, and the facility has no concerns. LPAs observed the facility to be clean and organized, and found no health and safety issues. LPAs 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. LPAs observed the electricity and water were running and the facility had soap and paper towels. Since the initial inspection on 02/24/23, AD had obtained and provided to LPAs R1’s Death Certificate dated 03/02/23 which states that R1 passed away from Cardiopulmonary Arrest, Congestive Heart Failure and Coronary Artery Disease at the facility. Based on the information obtained, R1 passed away from natural causes.

Based on the information obtained during the investigation, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. 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: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023
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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