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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530046
Report Date: 10/17/2022
Date Signed: 10/17/2022 01:08:55 PM

Document Has Been Signed on 10/17/2022 01:08 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:CRESTVIEW SENIOR HOME CAREFACILITY NUMBER:
335530046
ADMINISTRATOR:RAMOS, NIMFAFACILITY TYPE:
740
ADDRESS:4019 CRESTVIEW DRIVETELEPHONE:
(951) 226-8010
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY: 6CENSUS: 5DATE:
10/17/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Nimfa Ramos, AdministratorTIME COMPLETED:
12:45 PM
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Licensing Program Analyst Javier Prieto conducted a pre-licensing inspection with Licensee Nimfa Ramos. The inspection was conducted in person with Covid-19 restrictions.

The home is a (6) bedroom, (4) bath home with a living room and kitchen.
Per the approved fire clearance, the licensee is approved for 4 ambulatory residents. Bedrooms are furnished with bed, night stand, dresser and chair. Bedrooms have adequate lighting for residents’ use. The facility has linens, and towels and a sufficient amount of hygiene products for residents. Fire extinguisher was present and fully charged. Smoke detectors and carbon monoxide were tested and found to be in working order. The kitchen was observed to have dishes, silverware, pots, and pans. Cleaning supplies are locked and stored in kitchen area. Staff and resident files will be locked in cabinet located in the office area. The medications locked and stored in a locked cabinet. A first aid kit was present and observed to be complete. The backyard was observed to be fully fenced and had a covered patio with table and chairs for resident's comfort. Documents required are posted in public view were observed to be present. Comp III orientation was conducted during today's inspection with Mrs. Ramos.

During this time, LPA Prieto found no corrections needed. Facility appears ready for licensure.

An exit interview was conducted, and a copy of this report was given to Mrs Ramos for her review and signature
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2022
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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