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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880604
Report Date: 03/28/2026
Date Signed: 03/28/2026 11:30:35 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
08/28/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240828143219
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: 10DATE:
03/28/2026
UNANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:Edralene Jane Frijas- CaregiverTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff are mismanaging resident's medication(s) while in care.
Staff are not adequately supervising resident while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to deliver investigative findings. LPA met with Facility Caregiver Edralene Jane Frijas and explained the purpose of the visit regarding the allegations stated above.

First allegation: Staff are mismanaging resident's medication(s) while in care. Regarding the allegation stated above, LPA conducted a review of records during the review of records LPA discovered that on 8/28/2024 Resident #1 had arrived at the Adult Day Health Care Center looking upset. In addition, based on record it was later discovered by program staff that Resident #1 had medication in their possession. During further review LPA discovered that Resident #1 had a total of four (4) pills that were later identified by staff pharmacist to be controlled substance. Report also indicated that Resident #1 could not communicate where the medication came from. LPA conducted a file review pertaining to Resident #1 during the file review LPA discovered that Resident #1 cannot manage medication and that the facility is responsible for the storing and administration of medication for Resident #1.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2026
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-20240828143219
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CREST VILLA
FACILITY NUMBER: 331880604
VISIT DATE: 03/28/2026
NARRATIVE
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Second allegation: Staff are not adequately supervising resident while in care. Regarding the allegation stated above, LPA conducted a review of records pertaining to Resident #1 upon the review of records LPA discovered that on 8/28/2025 Resident #1 arrived at the Adult Day Health Care Center visually upset and crying, informing staff that five days ago Resident #1 had sustained a fall at home and was having pain on their right (R) rib. Based on the report LPA observed that the Care Center offered Resident #1 pain medication however, Resident #1 had pulled out a small bag with medication. In addition, records show that Resident #1 had slurred speech and could not communicate with staff. Based on the evidence gathered during the investigation, staff were not competent to observe Resident #1 condition and still allow resident to attend the Care Center while having medication in their possession. This determines that the above allegations are Substantiated. A finding that the complaint is Substantiated means that the findings are valid because the preponderance of the evidence standard has been met. Title 22 regulations Incidental Medical and Dental Care (h)(2), Personnel Requirements-General 87411 (a), from division 6, chapter, article 6, is cited on the attached LIC 9099 D.

An exit interview was conducted where this report, appeal rights, and LIC9099-D was discussed, and a copy of the report was provided to Facility Caregiver Edralene Jane Frijas at the of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20240828143219
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: CREST VILLA
FACILITY NUMBER: 331880604
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2026
Section Cited
CCR
87465(h)(2)
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87465 Incidental Medical and Dental Care....(h) The following requirements shall apply to medications which are centrally stored:.... (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidence by:
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The Licensee has agreed to read over: Incidental Medical and Dental Care regulation and provide training to all staff managing medication. And discuss the importance of keeping medication locked and secured, and following the proper measures to ensure medication is being taken by the resident. Proof of training will be emailed to LPA by POC 4/10/2026.
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Based on interviews, record review the licensee did not follow " Incidental Medical and Dental Care" resulting on Resident #1 to have controlled substance on their possesion, which poses an immediate Health, Safety, or Personal Rights risk to residents in care.
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Type B
04/10/2026
Section Cited
CCR
87411(a)
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Personnel Requirements - General....(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
This requirement is not met as evidence by:
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The Licensee has agreed to read over: Personnel Requirements - General regulation and provide training to all staff regarding observation and properly responding to residents change of conditions. Proof of training will be emailed to LPA by POC 4/10/2026.
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Based on interviews, record review the licensee did not follow "Personnel Requirements" to Resident #1 to observe residents change of condition, which poses an immediate Health, Safety, or Personal Rights risk to residents in care.
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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.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3