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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604355
Report Date: 10/03/2022
Date Signed: 10/03/2022 04:46:25 PM

Document Has Been Signed on 10/03/2022 04:46 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: 4DATE:
10/03/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:34 PM
MET WITH:Ivy Kasko, Co-AdministratorTIME COMPLETED:
04:52 PM
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Licensing Program Analyst (LPA), Chinwe Nwogene, conducted an unannounced visit to the facility to conduct a case management visit to address an incident involving the death of Client One (C1). LPA met with Co-Administrator, Ivy Kasko who was informed of the purpose of the visit.

The Department received a verbal notification from the facility on 9/29/2022 regarding the client's death on 9/29/2022 at 4.30am. A subsequent death report has not been received according to Ivy Kasko. A Special Incident Report (SIR) was given to LPA details, on 6/15/2022 the resident was admitted to Tri-City Hospital for possible infection. Resident was discharged on 6/20/2022 to La Paloma Healthcare center for rehabilitation, antibiotic and IV treatment. Resident was back and forth ER and hospital admission due to declining health. On 8/26/2022 resident was admitted to Bridge Hospice care.

No information was received by the LPA to indicate there was any lack of care and/or supervision. No citations have been issued at this time. This report was reviewed with Ivy Kasko and a copy was provided.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2022
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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