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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604355
Report Date: 05/17/2022
Date Signed: 05/17/2022 01:54:43 PM

Document Has Been Signed on 05/17/2022 01:54 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 HOME IIFACILITY NUMBER:
374604355
ADMINISTRATOR:DOWDEN, KATHERINEFACILITY TYPE:
735
ADDRESS:35822 BAY SABLE LN.TELEPHONE:
(760) 967-0119
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: 5CENSUS: 5DATE:
05/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:58 PM
MET WITH:Arlene Elad, Caregiver TIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by Caregiver Arlene Elad and explained the purpose of the visit. At the time of visit there were 2 staff and 2 residents present. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPAs toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer). Staff were also observed wearing appropriate face coverings (surgical masks). LPA observed that the facility staff had not been FIT tested for N95 masks, LPA provided the PIN 21-10-ASC providing FIT testing resources was provided.

The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks. The facility will contact the resident's physician should there be event of any COVID-19 related illnesses. The facility also has a designated infection control lead and cleans and disinfects the highly touched surfaces at minimum of 2 times a day and as needed

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and a copy of this report was provided to Arlene Elad, Caregiver.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
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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