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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601791
Report Date: 02/18/2023
Date Signed: 02/18/2023 09:39:36 AM

Document Has Been Signed on 02/18/2023 09:39 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CRYSTAL MANOR RESIDENTIAL CARE HOMEFACILITY NUMBER:
198601791
ADMINISTRATOR:CHRISTINA HADDADINFACILITY TYPE:
735
ADDRESS:3406 BALDWIN PARK BOULEVARDTELEPHONE:
(626) 337-1424
CITY:BALDWIN PARKSTATE: CAZIP CODE:
91706
CAPACITY: 26CENSUS: 22DATE:
02/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH: Christina HaddadinTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Christina Haddadin and discussed the purpose of today's visit.

This home consists of (13) bedrooms, (7) bathrooms (3 of which have showers), office, kitchen, pantry, dinning area and a detached laundry room/garage.

The following were observed/inspected: .
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility and throughout the facility. Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.
  • PPE supplies observed. Additional PPE supply stored inside the garage.
  • Hygiene supplies observed.
  • Bathrooms have hand soap and paper towels.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.
  • Staff responsible for direct care and supervision were wearing masks.
  • Clients will socially distance according to local public health guidelines.
  • Medication reviewed for Client #1 (C-1) through Client #4 (C-4). Medication is stored/locked inside the office.
  • Per Administrator, all clients and staff complete COVID-19 testing on Mondays as a precautionary measure.
  • Per Administrator, all clients have the COVID-19 vaccine and boosters.
  • Per Administrator, all staff have the COVID-19 vaccine and boosters.
Exit interview conducted, a copy of this report and Appeal Rights were provided to Christina Haddadin.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2023
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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