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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881820
Report Date: 08/14/2026
Date Signed: 08/14/2026 02:34:22 PM

Document Has Been Signed on 08/14/2026 02:34 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CRESTVIEW VILLAFACILITY NUMBER:
371881820
ADMINISTRATOR/
DIRECTOR:		POULSEN, MARKFACILITY TYPE:
740
ADDRESS:350 S VINE STREETTELEPHONE:
(760) 745-0160
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY: 42CENSUS: 29DATE:
08/14/2026
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Mark Poulsen - AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On 08/14/2026, Licensing Program Analyst (LPA) Aziz Faizi made an announced visit to the facility for the purpose of conducting a pre-licensing inspection due to a change of ownership. LPA met with Administrator Mark Poulsen, who accompanied LPA for the inspection. The Applicant has submitted an application for forty-two (42) residents.

The facility is a single-story home featuring thirty-five (35) bedrooms divided into six attached buildings including the kitchen and main office.

Each bedroom is equipped with its own full bathroom. At the center of the facility is a kitchen which prepares daily meals and snacks for all residents.

The bedrooms were observed to have bed, lighting, night stand, chest of drawers and area for sitting. The bathrooms had nonskid mats, and grab bars. There is plenty of extra linen (sheets, blankets, towels) that were observed to be in good repair. The smoke and carbon monoxide detectors were tested and found to be operable.

The hot water temperature was tested and was found to be within regulatory limits measuring at 106.1 degrees Fahrenheit. The facility has an emergency disaster plan, and infection control training plan on file. The facility has a sufficient supply of dishes, cooking and eating utensils, that were observed to be in good repair. The facility food supply was observed to be sufficient as there was a 7-day supply of nonperishable food items. There is a fully stocked first aid kit with manual.

Carolyn Tuba
Aziz Faizi
DATE: 08/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 VILLA
FACILITY NUMBER: 371881820
VISIT DATE: 08/14/2026
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Continued on LIC809-C....

The passageways, and ramps/inclines are clear and free from obstruction. The home has several fully charged fire extinguishers throughout the facility expiring on 06/19/2027. The facility does not have any known guns or ammunition stored on grounds. The medications will be kept in in a locked cabinet located in the main office.

The required postings (facility sketch, theft and loss policy, personal rights) were posted in the main office and dining room.

The facility was observed to have activities to encourage socialization such as board games and activities, as well as a covered patio with plenty of outdoor space for walking and physical activities in the living room of the facility.

Administrator is holding a valid adminstrator's license expiring on 09/28/2027.

LPA observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. LPA has determined that the facility meets the operational requirements for licensure. The Pre-licensing inspection is complete. 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 Mark Poulsen

NAME OF LICENSING PROGRAM MANAGER: Carolyn Tuba
NAME OF LICENSING PROGRAM ANALYST: Aziz Faizi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2026
LIC809 (FAS) - (06/04)
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