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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881531
Report Date: 10/02/2024
Date Signed: 10/02/2024 11:27:28 AM

Document Has Been Signed on 10/02/2024 11:27 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CRESTVIEW MANORFACILITY NUMBER:
371881531
ADMINISTRATOR/
DIRECTOR:
BRISTOL, AUDRAFACILITY TYPE:
740
ADDRESS:350 S. VINE STREETTELEPHONE:
(760) 745-0160
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY: 38CENSUS: 0DATE:
10/02/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator Audra BristolTIME VISIT/
INSPECTION COMPLETED:
11:35 AM
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Licensing Program Analysts (LPAs) Armando Perez and Abdoulaye Zerbo, conducted an announced visit for the purpose of conducting the pre licensing inspection. LPAs met with Administrator Audra Bristol for the visit. The applicant is seeking a change in ownership with residents in care for a residential care facility for the elderly, ages 60 and up. The facility is a single-story triplex compound with a capacity for 38 residents with 5 bedridden approved. On 07/08/24 the Fire Department of City of Escondido approved a fire clearance. LPAs toured the facility and observed the following:

LPAs inspected a sample of resident bedrooms and bathrooms. Resident bedrooms have the required bedding and furniture; such as clean mattresses, night stands, storage space, and sufficient lighting. Room temperatures were comfortable for residents in care. LPAs inspected a sample of resident bathrooms; the bathroom appliances were operating in safe and sanitary conditions. Showers contained non-slip surface and access to grab bars in the showers and next to toilets. LPAs measured the hot water temperature in the sampled bathrooms and measured within regulation. Bedrooms were equipped with a signal system to notify staff of any emergencies. LPAs toured the kitchen and dining area. The facility kitchen is locked and accessible only to staff. LPAs observed sharps and knives stored in an unlocked cabinet. Pantry was stocked with sufficient food to meet the required 2-day supply of perishable and 7-day supply of non-perishable food items. The facility had a menu posted and available for review. Dishes, glasses, and utensils were in good condition. LPAs observed two outdoor patio areas with each having a covering and sufficient seating for residents. The facility's main office is the centralized storage area where resident files, personnel files and medications are to be stored, locked, and inaccessible to the residents in care. LPAs verified the applicants Administrator Certification, with an expiration date of December 02, 2025 and the CPR certification, with the expiration date of March 21, 2026.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CRESTVIEW MANOR
FACILITY NUMBER: 371881531
VISIT DATE: 10/02/2024
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LPAs observed required postings including the visitation polices, emergency/disaster plans, complaint procedures, employee rights, personal rights and the Long-Term Care Ombudsman poster. Facility contains emergency supplies and first aid kits with the required items. The facility has working telephone for clients' use. LPAs observed several smoke detectors and carbon monoxide alarms throughout the facility. The facility has an emergency disaster plan and approved infection control training plan on file. The buildings and grounds were free from hazards. Outdoor and indoor passageways were kept free of obstruction. No bodies of water or firearms are being kept in the facility.

The facility has satisfied all requirements in accordance with Title 22, California Code of Regulations. An exit interview was conducted, and this report was discussed and provided to Administrator Audra Bristol.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC809 (FAS) - (06/04)
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