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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006198
Report Date: 10/06/2023
Date Signed: 10/06/2023 10:05:06 AM


Document Has Been Signed on 10/06/2023 10:05 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:CRESTAVILLAFACILITY NUMBER:
306006198
ADMINISTRATOR:MICHAEL OSTERBAUERFACILITY TYPE:
740
ADDRESS:30111 NIGUEL RDTELEPHONE:
(760) 804-5900
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:250CENSUS: 167DATE:
10/06/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Myra AragonesTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Joseph Alejandre conducted an unannounced collateral visit in conjunction with complaint investigation 22-AS-20231004114033 at another licensed facility. LPA was greeted and granted entry into the facility. LPA met with General Manager Myra Aragones and explained the reason for the visit.

During the visit, LPA met with Resident 1 (R1) to gather information pertaining to complaint #22-AS-20231004114033. Resident agreed to speak with LPA.

Exit interview conducted with the General Manager and a copy of this report was provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2023
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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