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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604355
Report Date: 05/17/2023
Date Signed: 05/17/2023 11:44:59 AM

Document Has Been Signed on 05/17/2023 11:44 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 HOME IIFACILITY NUMBER:
374604355
ADMINISTRATOR:DOWDEN, KATHERINEFACILITY TYPE:
735
ADDRESS:35822 BAY SABLE LN.TELEPHONE:
(760) 645-0088
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: 5CENSUS: 4DATE:
05/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Staff, Ivy KaskoTIME COMPLETED:
11:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit on 5/17/2023 at 09:24 a.m. LPA was granted entry and met with staff, Ivy Kasko, who was informed of the purpose of the visit. At the time of the visit there was (3) staff and (0) client present.

The facility is a two (2) story home with (8) bedrooms and (4) bathrooms with attached garage. No pools or firearms are being kept at the facility. The clients served are adults between the ages of 18-59. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff interviews. LPA observed the following:

Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training.



Physical Plant: LPA observed the client bedrooms and staff bedrooms. LPA observed the posted floor plan and the submitted floor plan did not match the current physical plant. The "loft" area on the second story was observed and confirmed by staff to be converted to (2) bedrooms. LPA observed these bedrooms were being used for staff. The licensee will receive a citation for this, and plan of correction was documented for this. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients in locked drawer. The smoke detector and carbon monoxide was operational, and the hot water temperature 106F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023
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 HOME II
FACILITY NUMBER: 374604355
VISIT DATE: 05/17/2023
NARRATIVE
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Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. LPA also reviewed the staff scheduled showing adequate staff coverage. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator, possesses a current administrator's certificate.

Record Review and Resident/Staff Files: LPA reviewed (2) staff files and training. All staff on LIC500 have criminal clearance and updated training along with CPR/First Aid Certification. During the tour, LPA was informed by staff that an unassociated individual had stayed in one of the staff bedrooms upstairs for the period of more than (5) days. LPA observed clothing and belongings in this room and was informed by staff that this belong to unassociated adult, Person #1 (P1). The facility will receive a citation and civil penalty of $500. Two (2) client files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in closet. LPA reviewed client medications for clients and found all medication listed on MARS and all required labeling was found to be in place.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire and earthquake drills, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the and first aid kit with all required items.

An exit interview was conducted where a copy of this report along with deficiency pages and appeal rights were reviewed and provided to staff, Ivy Kasko.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/17/2023 11:44 AM - It Cannot Be Edited


Created By: Janira Arreola On 05/17/2023 at 11:10 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 HOME II
FACILITY NUMBER: 374604355

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80086(c)
(c) Prior to construction or alterations, state or local law requires that all facilities secure a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above with the noted "loft" on the facility sketch on second floor, being converted into (2) staff rooms. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2023
Plan of Correction
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The licensee agreed to send the LPA an updated facility sketch along with building permits for the additional rooms that were added to the second story loft. This shall be done by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/17/2023 11:44 AM - It Cannot Be Edited


Created By: Janira Arreola On 05/17/2023 at 11:29 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 HOME II
FACILITY NUMBER: 374604355

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(2)
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above with P1 not being associated to the facility roster and having resided at the facility for more than (5) days. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2023
Plan of Correction
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The licensee agreed to send the LPA a transfer request for P1 by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023


LIC809 (FAS) - (06/04)
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