374603360-3-20-2023-18-AS-JARA-CQ4KSN-20230320080946

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603360
Report Date: 03/10/2023
Date Signed: 03/20/2023 08:10:12 AM

Document Has Been Signed on 03/20/2023 08:10 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	CREST CARE		FACILITY NUMBER:	374603360
ADMINISTRATOR:	KATHERINE DOWDEN		FACILITY TYPE:	735
ADDRESS:	3916 LIMBER PINE ROAD		TELEPHONE:	(760) 731-2220
CITY:	FALLBROOK	STATE: CA	ZIP CODE:	92028
CAPACITY: 4		CENSUS: 4	DATE:	03/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Licensee Katherine Dowden		TIME COMPLETED:	04:35 PM

NARRATIVE

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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit on 3/10/2023 at 02:00 p.m. LPA was granted entry and met with Licensee Katherine Dowden, who was informed of the purpose of the visit.

The facility is a one story facility with (7) bedrooms and (5) bathrooms for clients between the ages of 18-59. LPA conducted a tour of the interior and exterior of the facility and observed the following:

Infection Control: The LPA observed the hand washing stations in the facility. LPA also observed gloves at the facility and sharps container for needles. The facility is currently screening and taking temperature for facility visitors. The LPA also observed the COVID binder with infection control training, cleaning plan, and up to date guidance on COVID-19.

Physical Plant: LPA observed the clients bedrooms which contained the required furniture and personal rights postings. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair. The facility outdoor area was observed to have a pool with a locked fence making it inaccessible to clients.

Food Service: LPA observed the kitchen to be clean and possess equipment in good working condition. LPA observed the facility had the required 2-day perishable and 7-day non-pershibale food supplies. The sharp and dangerous objects are kept locked in the kitchen cabinets under the sink and next to the sink.

Care & Supervision/Administration: Adequate staff are present for the supervision of residents. Emergency exiting plans, emergency telephone numbers and personal rights were found posted in the facility.

Record Review and Resident/Staff Files: LPA observed staff had current CPR/First Aid Certification. The (2) resident files were also found to be complete.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CREST CARE	FACILITY NUMBER: 374603360
	VISIT DATE: 03/10/2023

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LPA conducted staff and client interviews while at the facility and reviewed facility documents. Due to time constraints the annual inspection was unable to be completed on this date. The LPA will return on a latter date to complete the inspection, The licensee was informed of this.

An exit interview was conducted where a copy of this report was reviewed and provided to Licensee, Katherine Dowden

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/20/2023 08:10 AM - It Cannot Be Edited

Created By: Janira Arreola On 03/13/2023 at 12:37 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CREST CARE	FACILITY NUMBER: 374603360
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1565(a)

Other Provisions

(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above as the facility did not have an emergency disaster plan that complied with HSC 15659(a). This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/13/2023
	Plan of Correction
1 2 3 4	The licensee agreed to send the LPA an updated LIC610D by the POC due date.

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:

Joel Esquivel

LICENSING EVALUATOR NAME:

Janira Arreola

LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

LIC809 (FAS) - (06/04)

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