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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530043
Report Date: 10/25/2022
Date Signed: 10/25/2022 10:33:58 AM

Document Has Been Signed on 10/25/2022 10:33 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, 744 P STREET, MS 9-14-8201
, CA 95814
FACILITY NAME:CRESTIGE CAREFACILITY NUMBER:
335530043
ADMINISTRATOR:DUENAS, HERSHEY ANN B.FACILITY TYPE:
740
ADDRESS:853 W CRESTVIEW STREETTELEPHONE:
(951) 496-3526
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY: 6CENSUS: 2DATE:
10/25/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Hershey Ann Duenas, Applicant/AdministratorTIME COMPLETED:
10:30 AM
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Component II completion: Successful

Facility Type: Residential Care Facility for Elderly (RCFE)
Application Type: Change in Ownership (CHOW)
Capacity: 6
Census (if any clients in care): 2
COMP II Participants: Hershey Ann Duenas, Administrator
Interview Method: Telephone interview

On October 25, 2022 at 10:00 AM, Applicant/Administrator participated in COMP II. Identification of the Applicant/administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicant/Administrator confirmed the understanding of the California Code Title 22 Regulations.

During COMP II, CAB Analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility Operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing Requirements/CPMB associations & Training
4. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with Applicant/Administrator. Report sent via email pdf and informed to return signed copy back to CAB close of business day today.
SUPERVISORS NAME: Joshua Miller
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2022
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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