374604426-9-1-2021-08-AS-NPED-C6FVRV-20210901164035

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604426
Report Date: 08/03/2021
Date Signed: 09/01/2021 04:41:08 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	CRESTVIEW HC LLC		FACILITY NUMBER:	374604426
ADMINISTRATOR:	DAYNES, ROBERT		FACILITY TYPE:	740
ADDRESS:	9825 GLEN CENTER DRIVE		TELEPHONE:	(858) 444-8560
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92131
CAPACITY:	64	CENSUS: 0	DATE:	08/03/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Administrator, Robert Daynes.		TIME COMPLETED:	11:20 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Natasha Persaud conducted a Prelicensing inspection. An initial application to operate a Residential Care Facility for the Elderly was received on 01/22/21. The facility was approved to care for sixty-four (64) Non-Ambulatory elderly residents. Hospice Waiver approved for six (6). The fire inspection was completed on 06/28/21. LPA met with Administrator, Robert Daynes, Executive Director, Meegan Kline, and Assisted Living Director, Lillian Escobar. During today's visit, a tour of the facility was conducted. According to Administrator, there will be no firearms or ammunition stored on site. All bodies of water were observed to have a metal grade and rocks to allow no more than 2 inches of water to gather. Indoor and outdoor passageways are free from obstructions. All window screens are clean and in good repair. Hallways are well-lit and night lights are available in the hallways. Fire smoke alarms, and carbon monoxide detectors were all observed and operational. Required furniture will be available as needed. There is sufficient closet and drawer space for resident belongings. Resident bathrooms are also in good repair; equipped with handrails and showers were equipped with non-skid shower mats. The facility maintains a supply of clean linens, sheets, bedspreads, blankets, pillowcases, mattress covers, and towels. The facility kitchen will be temporarily utilizing the kitchen from the independent living portion of the facility. There is an area for confidential storage for personnel and resident records, as well as a locked storage for residents medications. There is a shaded outdoor activity space, a common room available for visitors, and appropriate activity supplies. Continued on an LIC 809C.

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CRESTVIEW HC LLC	FACILITY NUMBER: 374604426
	VISIT DATE: 08/03/2021

NARRATIVE

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Facility has a first aid kit maintained at the facility. The facility has a locked storage area for disinfectants and cleaning supplies and other toxic chemicals. There is emergency lighting and supplies readily available for safety measures. The hot water temperature measured within compliance of 108 degrees in facility bathrooms. Administrator's Certification expires on 08/01/22

Component III was conducted at the facility with administrator Daynes. LPA Persaud reviewed continuing operational requirements, as well as record keeping and physical plant compliance. Based on today's evaluation, the facility is in compliance with CCR, Title 22 and the Health and Safety Code. Final approval is forwarded to management pending review. Pre-licensing inspection is complete and the facility has no deficiencies.

An exit interview was conducted, and a copy of this report, and Licensee's Rights (9058 01/16) will be sent to the Applicant's e-mail address. An electronic mail read receipt confirms delivery and receipt of these documents.

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

LIC809 (FAS) - (06/04)

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