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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530046
Report Date: 11/13/2024
Date Signed: 11/13/2024 03:45:50 PM

Document Has Been Signed on 11/13/2024 03:45 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/
DIRECTOR:		RAMOS, NIMFAFACILITY TYPE:
740
ADDRESS:4019 CRESTVIEW DRIVETELEPHONE:
(951) 226-8010
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY: 6CENSUS: 4DATE:
11/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Licensee/Administrator Nimfa RamosTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
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On 11/13/2024 at 11:45 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff and was granted entry to the facility. At the time of the visit there were three (3) staff present, and four (4) residents present. Licensee/Administrator Nimfa Ramos was informed of the visit. LPA Brown explained the purpose of the visit to Licensee/Administrator Ramos.

The facility is a six (6) bedroom, four (4) bathroom home with a kitchen, two (2) dining areas, two (2) living rooms, and an attached garage. The facility is a Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) non-ambulatory residents and one (1) resident may be bedridden. The current census is four (4) resident. LPA Brown was accompanied by Licensee/Administrator Ramos to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to interior and exterior passageways. The facility is maintained at a comfortable temperature of 72 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperature in the residents/staffs shared bathroom to be at 110 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Postings such as the facility license, personal rights, the CCLD complaint poster, ombudsman poster, labor laws, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. Medications are kept inside the medication cabinet in the kitchen inaccessible to residents. Overall, the facility is clean, in good repair for residents in care. ***Continuation in LIC809C***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 335530046
VISIT DATE: 11/13/2024
NARRATIVE
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Food Service: Seven (7) days non-perishable and two (2) days perishable food supply observed at the facility.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed two (2) resident files for admission agreements, updated physician reports, pre-placement appraisals, needs and services plans and centrally stored medications list. LPA Brown observed Resident #2 (R2) Pre-Admission Appraisal was incomplete as evidenced of no resident/responsible person signature and licensee/facility representative signature. Deficiency will be issued. LPA Brown observed incomplete Resident #2 (R2) Preplacement Needs & Services Plan (LIC625) as evidenced of no resident/responsible person signature noted in R2 form LIC625. Deficiency will be issued. LPA reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results. LPA Brown observed Staff #3 (S3) did not complete the required training in First Aid from persons qualified by such agencies as the American Cross. Deficiency will be issued. In addition, LPA Brown observed that the facility admitted two (2) bedridden residents on 08/25/2024 and per R1 and R2 Admission Agreements and Physician Reports (LIC602) and documents review, the facility's licensed for one (1) bedridden resident. Deficiency will be issued and a immediate civil penalty of $500.00 will be issued today for zero tolerance violation.

During Medication Audit, LPA Brown observed that staffs at the facility are not assisting Resident #1 (R1) with R1's one (1) medication per R1's Physician Order as evidenced of R1's one (1) medication was missing. Deficiency will be issued.

Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), LIC809D, LIC421IM and Appeal Rights were discussed and provided to Licensee/Administrator Nimfa Ramos.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 11/13/2024 03:45 PM - It Cannot Be Edited


Created By: Melody Brown On 11/13/2024 at 02:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: CRESTVIEW SENIOR HOME CARE
FACILITY NUMBER: 335530046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview and record review, the licensee did not comply with the section cited above by admitting two (2) bedridden residents on 08/25/2024 and the facility's licensed for one (1) bedridden which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2024
Plan of Correction
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Licensee stated to submit a Signed Statement of Understanding on CCR 87202(a)(2) and submit an appointment date to obtain Resident #2 (R2) updated Physician Report with Physician Signature and Signature Date to LPA Brown on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #3 (S3) completed the required First Aid Training by such agencies as the American Red Cross which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2024
Plan of Correction
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Licensee stated to submit proof of S3 registration/certification to complete the required First Aid to LPA Brown on POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 11/13/2024 03:45 PM - It Cannot Be Edited


Created By: Melody Brown On 11/13/2024 at 02:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: CRESTVIEW SENIOR HOME CARE
FACILITY NUMBER: 335530046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the facility are assisting Resident #1 (R1) with R1's one (1) medication per R1's Physician Order as evidenced of R1's one (1) medication was missing which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2024
Plan of Correction
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Licensee stated to train staffs on CCR 87465(a)(4) and submit proof of all staff training log to LPA Brown on Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 11/13/2024 03:45 PM - It Cannot Be Edited


Created By: Melody Brown On 11/13/2024 at 02:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: CRESTVIEW SENIOR HOME CARE
FACILITY NUMBER: 335530046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Resident #2 (R2) Pre-Admission Appraisal was complete as evidenced of no resident/responsible person signature and licensee/facility representative signature which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
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Licensee stated to submit a copy of R2's completed Pre-Admission Appraisal to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that Resident #2 (R2) Preplacement Needs & Services Plan (LIC625) as evidenced of no resident/responsible person signature noted in R2 form LIC625 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
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Licensee stated to submit a copy of R2's completed Preplacement Needs & Services Plan (LIC625) to LPA Brown on Plan of Correction (POC) due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2024


LIC809 (FAS) - (06/04)
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