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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601791
Report Date: 02/12/2024
Date Signed: 02/12/2024 04:31:42 PM

Document Has Been Signed on 02/12/2024 04:31 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, 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: 21DATE:
02/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Christina Haddadin / AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with Administrator Christina Haddadin who assist with the visit. LPA explained the reason for the visit. The facility is licensed to serve (26) twenty-six adults of which (4) four may be non-ambulatory.

The physical plant was inspected along with COVID-19 procedures, medications, food supply, and clients and staff records. LPA and Administrator toured the facility and inspected a random selection of client bedrooms, client bathrooms, kitchen, linen room, and laundry room. The patio areas are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the clients located near the entrance of the facility. Passageways and exits are free of obstruction. Extra linens, blankets, towels, and personal hygiene supplies were observed in the linen room and in the garage area. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and working properly. Sharps are locked and are inaccessible to clients. LPA observed laundry detergent, cleaning solutions/disinfectants are stored and locked in the laundry and in the garage area. Multiple fire extinguishers observed in the facility fully charged. Carbon monoxide/smoke detectors observed in the hallway and in the client rooms are operational. The water temperature was tested in all bathrooms. In the share bathroom between bedroom #12 and bedroom #13 water temperature was measured at 146.1-degree F which is not within the required 105F - 120F degrees F. Also, LPA observed that trash bins in the bathrooms have no covers. Client bedrooms have the required furniture and sufficient closet space. LPA observed that the furniture was broken in the clients bedrooms, missing handles on the cabinet's doors. In the bedroom # 12 closed door is broken. In the bedroom #11 the night stand door was missing. In the bedroom #9 window glass is broken / missing around the A/C and duct tape used instead. Clients beds are missing mattress pads. Continue 809C.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2024
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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Document Has Been Signed on 02/12/2024 04:31 PM - It Cannot Be Edited


Created By: Nune Margaryan On 02/12/2024 at 01:39 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CRYSTAL MANOR RESIDENTIAL CARE HOME
FACILITY NUMBER: 198601791

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. The water temperature was tested In the share bathroom between bedroom #12 and bedroom #13. Water temperature was measured at 146.1 degree F
which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2024
Plan of Correction
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Water temperature was adjusted at the time of visit. No further action required.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/12/2024 04:31 PM - It Cannot Be Edited


Created By: Nune Margaryan On 02/12/2024 at 01:39 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CRYSTAL MANOR RESIDENTIAL CARE HOME
FACILITY NUMBER: 198601791

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(f)(1)
Fixtures, Furniture, Equipment, and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers, including movable bins, used for storage of solid wastes shall have tight-fitting covers kept on the containers; shall be in good repair, shall be leakproof and rodent-proof.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. LPA observed that all trash bins in the bathrooms have no covers, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2024
Plan of Correction
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Licensee will purchase trash bins with cover and submit photos and receipts via email to LPA, by POC date.
Type B
Section Cited
CCR
85088(c)(4)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and wash cloths.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Clients beds are missing mattress pads.
which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2024
Plan of Correction
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Licensee will purchase mattress pads for clients beds and submit photos and receipts via email, by POC 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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/12/2024 04:31 PM - It Cannot Be Edited


Created By: Nune Margaryan On 02/12/2024 at 03:21 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CRYSTAL MANOR RESIDENTIAL CARE HOME
FACILITY NUMBER: 198601791

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. In the bedroom # 12 closet door is broken /missing, In the bedroom #11 the night stand door is broken/missing,missing handles on the cabinet's doors.
In the bedroom #9 window glass is broken / missing around the A/C and duck tape used instead.


which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2024
Plan of Correction
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Licensee will ensure replacement or repair furniture and window
and submit photos and receipts via email , by POC 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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024


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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CRYSTAL MANOR RESIDENTIAL CARE HOME
FACILITY NUMBER: 198601791
VISIT DATE: 02/12/2024
NARRATIVE
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The First Aid kit was fully stocked with all required items including a current manual.The medications are centrally stored in the office room and are inaccessible to clients. LPA reviewed clients and staff files. LPA confirmed staff working have fingerprint clearances. LPA reviewed clients medications. Medications are documented properly and given as prescribed.

Observed deficiency is documented on 809D.

Exit interview conducted with Administrator and the copy of the report and appeal rights are provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024
LIC809 (FAS) - (06/04)
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