330905299-8-27-2021-18-AS-EMAN-C6F4XG-20210831192930

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 330905299
Report Date: 08/27/2021
Date Signed: 08/27/2021 01:57:13 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/26/2020 and conducted by Evaluator Stephanie Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200526091927

FACILITY NAME:	CREST HOME FOR THE ELDERLY		FACILITY NUMBER:	330905299
ADMINISTRATOR:	RAMASAR, OSCAR		FACILITY TYPE:	740
ADDRESS:	4460 CREST VIEW DRIVE		TELEPHONE:	(951) 736-2921
CITY:	NORCO	STATE: CA	ZIP CODE:	91760
CAPACITY:	29	CENSUS: 19	DATE:	08/27/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Yovana Solorio		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident sustained injuries while in care
Staff failed to seek medical attention in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to deliver findings for the above allegations. LPA met with Caregiver, Yovana Solorio, and discussed the purpose of the visit. The investigation consisted of interviews with staff and residents.

In regards to allegation #1, Department staff interviewed Resident #1 (R1) who could not provide consistent statements regarding the alleged eyewitnessed abuse of Resident #2 (R2). Department staff also interviewed Staff #1 (S1) and Staff #2 (S2) who denied that R1 sustained injuries caused by another resident in the facility. S1 stated that R2's injuries were caused by an unwitnessed fall. Department staff was unable to interview R2 due to condition of the resident. Due to conflicting interviewee statements and lack of evidence to corroborate the allegation; the allegation is unsubstantiated.

In regards to allegation #2, LPA interviewed S1 and S2 who both stated that R2 was assessed and monitored for injuries after experiencing an unwitnessed fall. S1 stated that S2 immediately contacted R2's hospice

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200526091927

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CREST HOME FOR THE ELDERLY	FACILITY NUMBER: 330905299
	VISIT DATE: 08/27/2021

NARRATIVE

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agency; who then came to the facility to conduct an assessment of R2. S1 stated that Witness #1 (W1) advised that R2 did not need to be sent to the emergency room. LPA interviewed W1 who confirmed that upon assessing R2, W1 advised facility staff that R2 did not need to be sent to the emergency room. Due to lack of evidence to corroborate the allegation; the allegation is unsubstantiated.

Based on evidence obtained during the investigation, LPA has determined that the above allegations are UNSUBSTANTIATED; meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where this report (LIC 9099 & LIC 9099C) was discussed and a copy was provided to Solorio at the conclusion of the investigation.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021

LIC9099 (FAS) - (06/04)

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