<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330905299
Report Date: 11/02/2023
Date Signed: 11/02/2023 03:57:59 PM


Document Has Been Signed on 11/02/2023 03:57 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



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: 23DATE:
11/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:21 AM
MET WITH:Ghislaine RamasarTIME COMPLETED:
04:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
09020; Licensing Program Analysts (LPAs) Amy Goldenberg and Bianca Wolcott conducted an unannounced visit to the facility for the purpose of a required annual. LPAs rang the bell and were granted entry by LVN Ravinder Ahuja. LPAs discussed the purpose of the visit. LPAs were later met by Licensee Ghislaine Ramasar.

LPAs toured the facility inside and out. The facility has no bodies of water or firearms. The facility has charged fire extinguishers, operating smoke alarms, and carbon monoxide detectors. All indoor and outdoor passageways were kept free of obstruction. Cleaning supplies, medications, and sharps were locked and kept inaccessible to the clients. All client bedrooms had sufficient lighting. The facility had a supply of additional linen and extra hygiene items for the clients. In terms of the food supply, the facility had a sufficient amount of nonperishable and perishable food items. LPA measured the hot water temperatures in three resident bathrooms ranging 105-112 degrees F.

LPAs reviewed staff and client files. Client files had appropriate documentation including an admission's agreement. Staff files had appropriate documentation including current first aid/CPR certification and a health screening report. LPAs learned that E1's criminal record clearance has not been associated tho this facility number. LPAs reviewed medications. Medications appeared to be dispensed appropriately according to the physician's orders. Centrally stored medication logs are maintained.

This reports was reviewed with and a copy was provided to the facility representative. Refer to LIC809D for deficiencies cited. Appeal rights were discussed and provided to Ghislaine Ramasar.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Bianca WolcottTELEPHONE: (951) 248-0306
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 11/02/2023 03:57 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
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: 11/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on Guardian Review the licensee did not comply with the section cited above in one of five employee records reviewed LIcensee failed to associate E1 to the facility number, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
1
2
3
4
Licensee to associate E1 to the facility number by POC due date and submit proof to CCL.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Bianca WolcottTELEPHONE: (951) 248-0306
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2