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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604355
Report Date: 03/27/2026
Date Signed: 03/27/2026 11:41:34 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/11/2023 and conducted by Evaluator Antonine Richard
COMPLAINT CONTROL NUMBER: 18-AS-20230911132847
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:
03/27/2026
UNANNOUNCEDTIME BEGAN:
07:58 AM
MET WITH:DOWDEN KATHERINETIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility is over medicating resident in care.
Facility Licensee and Administrator are neglecting resident in care.
INVESTIGATION FINDINGS:
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On March 27, 2026, at approximately 8:00 AM, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent unannounced complaint visit. LPA met the Administrator Katherine Dowden, and LPA Richard explained the purpose of this visit.

The investigation consisted of the following: The California Department of Social Services (CDSS) interviewed the Licensee, the Administrator (A1), three staff members (S1-S3), four clients (C1-C4), and the Case Worker (CW). The department reviewed these documents: the Client’s Roster, Staff Roster, a copy of (C1)’s face sheet, the Admission Agreement dated 08/18/2003, (C1)’s Physician’s Report for Community Care Facilities (dated 08/21/2025), the list of medications, and the Medication Administration Records (MAR) dated 03/01/2026. C1 was discharged from the hospital on 09/10/2023. The department also reviewed and obtained Staff training records from Relias continuing education, dated October 2025.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 18-AS-20230911132847
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/27/2026
NARRATIVE
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Allegation #1: Facility is over-medicating the resident in care.

The complaint alleged that the licensee and the administrator over-medicated the client. On March 27, 2026, the department interviewed the licensee, who denied the allegation and stated that staff were trained to assist clients with their medications. They also indicated that the staff followed the doctor's orders and that the medications were accompanied by pharmacy instructions.

At the same time, the department interviewed the administrator (A1), who also denied the allegation and stated that the medication arrived with the doctor's orders, and that they adhered to these instructions while assisting clients.

During the March 27, 2026, the department interviewed four clients (C1-C4). Three of the four clients were unable to respond to any of the department's questions due to cognitive impairments. However, C1 was able to answer all questions, denied being over-medicated, and stated that the medications were necessary for their health. C1 mentioned taking several medications each day.

Additionally, on March 27, 2026, the department interviewed the caseworker, who denied ever receiving any complaints regarding C1 being over-medicated. On the same day, the department reviewed an Unusual Incident Report (UIR) dated July 8, 2023, which indicated that staff took C1 to the emergency room (ER) due to balance issues. C1 was released the same day.

Report continued on LIC9099C

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20230911132847
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/27/2026
NARRATIVE
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Furthermore, the department reviewed another UIR dated September 9, 2023, where staff took C1 to the ER because C1 was feeling weak. The records from Try City Medical Center confirmed that C1 was hospitalized and discharged on September 10, 2023.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is unsubstantiated.

Allegation #2: The facility and the administrator are neglecting the resident in care.

The complaint alleged that the Licensee and the administrator neglected the resident in care. On March 27, 2026, the department interviewed the licensee, who denied the allegation. The licensee explained that the client left the facility at 7:30 AM to attend a day program and returned at 3:30 PM. When the client arrived home, the facility staff was ready to assist with any activities they wanted to pursue. The licensee also mentioned that the clients enjoy watching TV, playing games, walking, and exercising.

During the same visit, the department interviewed the administrator (A1), who also denied the allegation. A1 stated that the day program would have contacted the facility to report any issues if the clients had arrived dirty, hungry, or unkempt.

Report Continued on LIC9099C

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20230911132847
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/27/2026
NARRATIVE
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On the same day, the department interviewed three staff members (S1-S3), all of whom denied the allegations and asserted that they would never neglect clients. Additionally, four clients (C1-C4) were interviewed; three of them were unable to respond to the department's questions. However, C1 expressed satisfaction with living at the facility and stated that the staff takes good care of them.

The department also interviewed the caseworker, who reported having received no complaints about C1 being neglected at the facility. Furthermore, the department observed four clients leaving the facility to attend the day program, all well-dressed and assisted by staff as they boarded the vehicle.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies were cited.

An exit interview was conducted. A copy of the report was provided to staff member Arlene Elad.

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4