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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006198
Report Date: 12/14/2024
Date Signed: 12/14/2024 05:06:19 PM

Document Has Been Signed on 12/14/2024 05:06 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CRESTAVILLAFACILITY NUMBER:
306006198
ADMINISTRATOR/
DIRECTOR:		MYRA ARAGONESFACILITY TYPE:
740
ADDRESS:30111 NIGUEL RDTELEPHONE:
(760) 804-5900
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 250TOTAL ENROLLED CHILDREN: 0CENSUS: 194DATE:
12/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:31 AM
MET WITH:Paola Carrillo TIME VISIT/
INSPECTION COMPLETED:
03:02 PM
NARRATIVE
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On 12/14/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Hospitality Director Paola Carrillo who contacted the Executive Director Myra Aragones by telephone. LPA Dabuet explained the purpose of today’s visit. The facility is licensed to operate for (250) non-ambulatory, of which (10) may be bedridden elderly adults ages 60 and above. The facility is approved for (20) hospice residents. Currently the facility has (164) assisted living residents, (30) residents in memory care, and (6) hospice residents.

The facility is a three-story structure located in a commercial neighborhood. It consists of the following: (211) resident bedrooms, (211) resident bathrooms, med rooms, a conference room, dining rooms, a laundry room, a mailroom, business offices, a commercial kitchen, a movie theater, (3) multi-purpose rooms, (8) storage rooms, (13) public restrooms, courtyard patio area, a salon, an exterior pool, an employee lounge, and rooftop with art & crafts room, sun room area and lounge.

LPA Dabuet and Maintenance Director David Deger toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. The resident rooms were inspected: #106, #112, #127, #132, #250, #274, #373 and #381. Emergency call buttons were in working condition. Bathrooms were operational with water temperature measured at 105.2 – 110.1 degrees F. A comfortable temperature was maintained in the facility at 70 - 74 degrees F.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately.

(Evaluation Report continues LIC 809-C)
Janae HammondTELEPHONE: (323) 395-3554
Ernand DabuetTELEPHONE: (323) 629-5526
DATE: 12/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CRESTAVILLA
FACILITY NUMBER: 306006198
VISIT DATE: 12/14/2024
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Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable in each resident's room. Disaster Drill/Evacuation Drill/Fire Drill are conducted with records of 10/17/24 being the last drill. Facility fire cleared approved for delayed egress exits. Facility has delayed egress exit doors in memory care all operable condition.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted including Activities Calendar and Food Menu.

LPA conducted an audit of resident #1-#7 (R1-R7) out of (194) service files, and staff #1-#7 (S1-S7) out of (142) personnel files were complete. A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurately. The facility is current in CCLD annual fees. The administrator certificate for Myra Aragones #7008607740 effective 10/01/2023 - 09/30/2025. The facility has a Liability Insurance Certificate valid with policy # NSC1000498 effective 06/01/24 – 06/01/25.

DEFICIENCIES:

  • Criminal Clearance Transfer Association for staff #8. No Criminal Clearance Transfer Request LIC 9162 on file or included on CDSS Guardian Background System as being associated.
  • Staff #7 did not have current CPR/First Aid Certificate on file last CPR expired 10/2024.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 809-D).

An exit interview conducted with the Myra Aragones, and a copy of the report is provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 395-3554
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/14/2024 05:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing, or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. LPA identified staff #8 (S8) did not have criminal record clearance transfer. Staff did not have an LIC 9162 on file nor transferred on CDSS Guardian. This violation which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 12/16/2024
Plan of Correction
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Licensee will ensure all staff have criminal clearance transfer prior to working at the facility. Staff #8 (S8) according to CDSS Guardian is not associated to this facility. Licensee will associate staff #8 (S8) by POC due date. Send proof of correction by email to ernand.dabuet@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Janae HammondTELEPHONE: (323) 395-3554
Ernand DabuetTELEPHONE: (323) 629-5526

DATE: 12/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2024

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/14/2024 05:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
80075(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. Staff #7 did not have First Aid/CPR certificate on file. This violation which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 12/28/2024
Plan of Correction
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Licensee will ensure all facility staff must have the mandatory First Aid/CPR Training completed. As plan of correction, administrator will send proof of completed First Aid/CPR will be sent to LPA via email: ernand.dabuet@dss.ca.gov before POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Janae HammondTELEPHONE: (323) 395-3554
Ernand DabuetTELEPHONE: (323) 629-5526

DATE: 12/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2024

LIC809 (FAS) - (06/04)
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