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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603360
Report Date: 03/13/2023
Date Signed: 03/13/2023 12:56:28 PM

Document Has Been Signed on 03/13/2023 12:56 PM - 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 CAREFACILITY NUMBER:
374603360
ADMINISTRATOR:KATHERINE DOWDENFACILITY TYPE:
735
ADDRESS:3916 LIMBER PINE ROADTELEPHONE:
(760) 731-2220
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: 4CENSUS: 4DATE:
03/13/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Licensee, Katherine DowdenTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA), Janira Arreola, made an unannounced visit to the facility in order to conduct the an annual continuation visit that was not completed on 3/10/2023 due to time constraints. LPA was granted entry by and met with the licensee, Katherine Dowden who was informed of the purpose of the visit.

Physical Plant: LPA reviewed the facility's license and facility sketch. LAP found that the facility is currently operating within the limitations of their licensee for (4) non-ambulatory clients (1) of which can be bedridden. The facility hot water temperature was recorded at 109F and the fire alarms and carbon monoxide detectors were in good working condition.

Staffing: LPA conducted (2) staff interviews. It was found that staff #1 (S1) had difficulty answering questions #5 and #6 relating to client personal rights, reporting of abuse, types of client abuse, and S1 expressed their English was not "good". LPA reviewed the file for S1 and interviewed the licensee. Hiring practices, staff qualifications, and training practices were discussed with the licensee. LPA reviewed progress notes that were written by S1, reviewed training for personal right was last conducted on 9/19/2022 and training on abuse was last conducted on 11/15/2020. In the staff file LPA reviewed S1's LIC501 and reviewed staffs qualifications and past work experience. Based on the information reviewed LPA will issue a technical violation advising the Licensee to retrain staff in the areas described.

Incidental Medical: LPA reviewed the medications for (2) residents and found that all resident medications were accounted for, with proper labeling, and medication administration log was found to be accurate and up to date.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2023
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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Document Has Been Signed on 03/13/2023 12:56 PM - It Cannot Be Edited


Created By: Janira Arreola On 03/13/2023 at 09:56 AM
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: 03/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/18/2023
Section Cited
CCR
80065(f)

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(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.
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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.
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)
Page: 2 of 3
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: 03/13/2023
NARRATIVE
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Disaster Preparedness: LPA reviewed the facility's current emergency disaster sheet this is the previous LIC610D. LPA provided the licensee with updated LIC610D form from the deportment website, as well as PIN 22-01 ASC. The licensee was unable to provide the LPA with an updated Emergency and Disaster Plan that would satisfy the PIN 22-01 ASC based on the Health and Safety Code. LPA will issue a Type B deficiency for this. A plan of correction was documented with the licensee.

An exit interview where a copy of this report along with LIC809-D page, and appeal rights were provided to Licensee, Kathrine Dowden.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023
LIC809 (FAS) - (06/04)
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