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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601726
Report Date: 02/07/2022
Date Signed: 02/08/2022 08:22:41 AM

Document Has Been Signed on 02/08/2022 08:22 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:CREST HOME IIIFACILITY NUMBER:
374601726
ADMINISTRATOR:KATHERINE DOWDENFACILITY TYPE:
735
ADDRESS:4791 MARBLEHEAD BAY DRIVETELEPHONE:
(760) 754-1550
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY: 6CENSUS: 6DATE:
02/07/2022
TYPE OF VISIT:Case Management - COVID-19ANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Ivy KaskoTIME COMPLETED:
02:28 PM
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Licensing Program Analyst (LPA), Kristina Ryan, and County of San Diego Nurse HAI Site Assessment Contractor, Elizar Perez conducted an announced on-site visit. The team identified themselves and discussed the purpose of the visit with Administrator, Ivy Kasko.

The Department conducted the on-site visit to provide technical assistance and to evaluate the facility's disinfection, testing surveillance, screening protocols as well as the use of personal protective equipment. The Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Report (LIC 808) was reviewed. During today's visit, the team interviewed Ms. Kasko and conducted a walk-through of the facility. A debriefing was conducted with Ms. Kasko at the conclusion of the visit.

During today's visit, no deficiencies were issued. An exit interview was conducted with Ms. Kasko and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to the administrator via electronic mail. An electronic receipt confirms receipt of the documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Kristina Ryan
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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