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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880604
Report Date: 06/16/2023
Date Signed: 07/14/2023 02:19:30 PM

Unsubstantiated


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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/06/2022 and conducted by Evaluator Amy Goldenberg
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220506103835
FACILITY NAME:CREST VILLAFACILITY NUMBER:
331880604
ADMINISTRATOR:RAMASAR, OSCARFACILITY TYPE:
740
ADDRESS:4014 CALIFORNIA AVETELEPHONE:
(951) 268-6040
CITY:NORCOSTATE: CAZIP CODE:
92860
CAPACITY:15CENSUS: 11DATE:
06/16/2023
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Oscar Ramasar and Administrator/LicenseeTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff mismanaged resident's medication
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This unannounced visit by Amy Goldenberg, Licensing Program Analyst (LPA), is to conclude investigation into the above-mentioned complaint allegation. During the course of the investigation, interviews were conducted with two (2) care giving staff, interviews were conducted with five (5) of eleven (11) residents residing in the home, a review of resident records was completed and copy of medication records for R1 were obtained dated March and April 2022. Investigation revealed the following information: It is alleged that the facility staff mismanage R1's medications. Review of medication records do not reveal any indication that the facility staff have mismanaged R1's medications. Two (2) of Two (2) staff interviewed deny mismanaging resident medications. Five (5) of five (5) residents interviewed deny staff mismanage or deny them their medication, indicate that they always receive their medication, and that they feel safe in the home. We have found the complaint allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and furnished to the facility representative.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023
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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