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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601726
Report Date: 09/27/2022
Date Signed: 09/27/2022 11:53:32 AM

Document Has Been Signed on 09/27/2022 11:53 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:
09/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Ivy KaskoTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA identified herself to, was allowed entry by, and explained the purpose of the visit to Co-Administrator Ivy Kasko.

During today’s visit, LPA conducted a tour of the facility and observed the clients in care. In accordance with the Department’s Infection Control, LPA provided technical assistance, observed, and evaluated the facility's implementation of their COVID-19 Mitigation Plan, to include disinfection, testing, vaccination, screening protocols, and the use of personal protective equipment.

No deficiencies were cited or observed on this date. An exit interview was conducted with Co-Administrator Ivy Kasko, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2022
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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