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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 330905299
Report Date: 10/18/2024
Date Signed: 10/18/2024 05:44:36 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
10/15/2024 and conducted by Evaluator Raquel Hernandez
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241015113034
FACILITY NAME:CREST HOME FOR THE ELDERLYFACILITY NUMBER:
330905299
ADMINISTRATOR:RAMASAR, OSCARFACILITY TYPE:
740
ADDRESS:4460 CREST VIEW DRIVETELEPHONE:
(951) 736-2921
CITY:NORCOSTATE: CAZIP CODE:
92860
CAPACITY:29CENSUS: 29DATE:
10/18/2024
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:House Manager Florence NahinTIME COMPLETED:
05:55 PM
ALLEGATION(S):
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Staff did not properly supervise resident, resulting in resident wandering away.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Raquel Hernandez and Mary Rico conducted an unnannounced visit for the purpose of investigating the above allegation. LPAs met with House Manager Florence Nahin and explained the purpose of the visit. The investigation consisted of staff interviews, resident interviews and facility tour.

For the allegation, Staff did not properly supervise resident, resulting in resident wandering away.

LPA Hernandez conducted (4) resident interviews and (4) staff interviews. During resident interview R1 admitted to leaving the facility without care and supervision. Additionally, 3 out of the 4 staff admitted R1 left without care and supervision.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Raquel HernandezTELEPHONE: 951-248-0336
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 56-AS-20241015113034
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CREST HOME FOR THE ELDERLY
FACILITY NUMBER: 330905299
VISIT DATE: 10/18/2024
NARRATIVE
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During record review, LPAs Hernandez and Rico observed R1's physician report and it states R1 has confusion and wandering behavior that requires 24 hour care and supervision.



Based on observations, interviews, and record review, the allegations are SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

During today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report LIC9099, LIC9099C and LIC9099D were discussed and provided to House Manager Florence Nahin and discussed over the phone with licensee Ghislaine Ramasar and Oscar Ramasar along with a copy of the appeal rights.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Raquel HernandezTELEPHONE: 951-248-0336
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20241015113034
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CREST HOME FOR THE ELDERLY
FACILITY NUMBER: 330905299
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/21/2024
Section Cited
HSC
1569.312(e)
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1569.312 Basic Service Requirements (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, saftey, and well-being.
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Licensee stated to submit proof of staff training on supervision rules to LPA Hernandez
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Based on interviews, licensee failed to meet this requirement by not ensuring staff were properly supervising residents, which poses an immediate health, saftey or personal rights risk to persons in care.
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 by Plan of Correction (POC) due date 10/21/2024.
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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.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Raquel HernandezTELEPHONE: 951-248-0336
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3