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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197418475
Report Date: 09/15/2021
Date Signed: 09/15/2021 01:16:09 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:CRYSTAL STAIRS INC.- SULLIVANFACILITY NUMBER:
197418475
ADMINISTRATOR:JONES-LOWE, CONNIEFACILITY TYPE:
850
ADDRESS:725 W. RAYMOND STREETTELEPHONE:
(310) 933-0760
CITY:COMPTONSTATE: CAZIP CODE:
90220
CAPACITY:120CENSUS: 51DATE:
09/15/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:41 AM
MET WITH:Kimberly Hargrave- Education Coordinator TIME COMPLETED:
01:15 PM
NARRATIVE
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An unannounced Case Management Inspection was conducted on this day by Licensing Program Analyst (LPA) Alicia Bailey to address an Unusual Incident Report that was received in the licensing office on 11/22/2019. LPA met with Education Coordinator Kimberly Hargrave at 10:26 am.

LPA Bailey and Education Coordinator toured the facility, at the time of the inspection all ratios were compliant according to Title 22 Regulations.

On 11/22/2019 Child # 1 was sitting at the computer table he fell backward and hit his head on a wood table. Child # 1 sustained a bump and cut that was bleeding on the back of his head. Staff # 1 applied pressure with a wet paper towel. Child # 1 parent was called he was taken to the doctor and received two staples. Child # 1 return back to school. At this time Child # 1 no longer attends the school due to age requirement .

Based on today’s inspection, and interviews conducted, the facility followed the appropriate Reporting Requirements, Notified Parent, no follow-up is necessary regarding the incident. Education Coordinator followed the required protocol for reporting requirements" as the incident was reported to Child Care Licensing. It does not appear this incident was the result of a Title 22 violation and the facility followed the appropriate regulations to care for the children in care. No deficiencies were cited on this date.



SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Alicia BaileyTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: CRYSTAL STAIRS INC.- SULLIVAN
FACILITY NUMBER: 197418475
VISIT DATE: 09/15/2021
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Upon receipt, Notice of Site Visit shall be posted for thirty (30) days. Failure to maintain posting as required will result in a $100 civil penalty.

An exit interview was conducted, and a copy of this report was provided to Education Coordinator Kimberly Hargrave. Notice of Site visit was issued
SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Alicia BaileyTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
LIC809 (FAS) - (06/04)
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