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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604355
Report Date: 05/03/2024
Date Signed: 05/03/2024 02:53:46 PM

Document Has Been Signed on 05/03/2024 02:53 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CREST HOME IIFACILITY NUMBER:
374604355
ADMINISTRATOR/
DIRECTOR:		DOWDEN, KATHERINEFACILITY TYPE:
735
ADDRESS:35822 BAY SABLE LN.TELEPHONE:
(760) 645-0088
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: 5CENSUS: 4DATE:
05/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:25 PM
MET WITH:Ivy Kasko, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:05 PM
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On 5/3/24 Licensing Program Analyst (LPA) Javina George conducted an unannounced annual/1 year required visit. LPA was granted entry by caregiver Elisa Dabu, who was informed of the purpose of the visit. The Assistant Administrator Ivy Kasko arrived 30 minutes after LPAs arrival. At the time of the visit there was (3) staff and (0) residents present. All staff present were observed to have obtained proper fingerprint clearance and were associated to the facility. LPA observed the following during today's visit:

The facility is a two (2) story home with (8) bedrooms and (4) bathrooms with attached garage. The facility was observed to be clean and clutter free. On the first floor of the facility there is a total of 3 resident bedrooms, (2 individual and 1 shared). The water temperature was checked in the resident bathrooms and was found to be within regulatory limits as it measured at 112. degrees F.

The second story of the facility is designated for staff, as there is a total of 5 bedrooms, which is also reflected the posted facility sketch that is on file. The exterior-backyard area was observed to be free of hazards. The sharp and dangerous objects were observed to be locked and inaccessible to residents in care as they are stored in a locked cabinet in the kitchen next to the water cooler. The facility was observed to have the required 2-day supply of perishable and 7-day supply of non-perishable foods. LPA observed for there to be expired Brussels sprouts and broccoli that was discarded during LPAs visit.



The facility was observed to have fully charged fire extinguishers. The emergency disaster drills are being conducted on a quarterly basis and the last drill was conducted on 3/19/24. The combined smoke and carbon monoxide detectors were tested and were observed to be operable. There are no known guns or ammunition on the premises. There are no pools or bodies of water.

Resident medication was observed to be locked in armor style cabinet in the hallway. LPA reviewed resident medications for all 4 and observed for the medication to be given according to the physicians instructions .
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CREST HOME II
FACILITY NUMBER: 374604355
VISIT DATE: 05/03/2024
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The facility was observed to have the Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator Katherine Dowden, possesses a current administrator's certificate that expires on 12/18/24. Please note that assistant Administrator Ivy Kasko's admin certification expires on 8/19/25.

LPA reviewed (3) staff files and training for staff present at the facility. All staff files reviewed were observed to have received ongoing training as well as current CPR/First Aid Certification. All 4 resident files were reviewed and were found to have the required documentation. The resident Personal and Incidental (P&I) funds were counted and observed to be balanced and matched the amount indicated on the P&I log.

Based on today's inspection no deficiencies were issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 6).

An exit interview was conducted where a copy of this report and LIC811-confidential names list were reviewed and provided to Administrator, Ivy Kasko.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC809 (FAS) - (06/04)
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