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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530043
Report Date: 02/06/2024
Date Signed: 02/06/2024 02:22:36 PM

Document Has Been Signed on 02/06/2024 02:22 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CRESTIGE CAREFACILITY NUMBER:
335530043
ADMINISTRATOR:DUENAS, HERSHEY ANN B.FACILITY TYPE:
740
ADDRESS:853 W CRESTVIEW STREETTELEPHONE:
(951) 496-3526
CITY:CORONASTATE: CAZIP CODE:
92882
CAPACITY: 6CENSUS: DATE:
02/06/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Glen Bagro TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Mary Rico arrived at the facility to conduct an unannounced case management visit. LPA met with caregiver Glen Bagro and explained the reason for today’s visit.

During a prior visit on 1/8/2024 LPA discovered the facility garage was converted into a bedroom. During this visit, the facility was given a deficiency and plan of correction to convert the garage back to the original facility sketch.

During today’s visit, LPA observed the garage was converted back to the original facility sketch.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to caregiver Glen Bagro.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2024
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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