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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601791
Report Date: 10/21/2022
Date Signed: 10/21/2022 10:53:40 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/16/2021 and conducted by Evaluator Elizabeth Ceniceros
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210716091112
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: 25DATE:
10/21/2022
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator Christina HaddadinTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility is not providing food of the quality or quantity necessary to meet client's needs.

Licensee did not ensure that communications to the facility from client's relatives were answered promptly and completely.

Licensee did not ensure that planned recreational activities were provided for the clients.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Administrator (A1: Christina Haddadin). LPA/RA spoke to A1 prior to entering the facility to conduct a risk assessment. A1 informed LPA/RA that the facility had one (1) COVID case; however, all staff and remainder of clients did not have symptoms. The purpose of today’s visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegations. The initial 10-Day visit was conducted by LPA Nicol Wesley on 07/23/21 with Administrator.

LPA/RA Ceniceros interviewed (between 8:15 a.m. - 8:45 a.m.) two (2) facility staff members and two (2) clients in care. Client #1 could not be interviewed as the client voluntarily moved out of the facility, effective 04/01/22. Clients in care were attending their adult day program from 7:00 a.m. to 3:00 p.m. LPA/RA Ceniceros reviewed (between 8:45 a.m. – 9:30 a.m.) the requested documentation: Admissions Agreement (dated 02/01/15), Emergency I.D. & Information (dated 02/05/15), Physician’s Report (dated 02/21/20), Power of Attorney/Conservator (dated 07/21/16), Appraisal/Needs & Services Plan (dated 06/20/20),
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Araceli Ramirez
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Ceniceros
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20210716091112
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/21/2022
NARRATIVE
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and Record of Client's Safeguarded Cash Resources (2021/2022) for Client #1 (C1); facility's staff and clients' rosters, Activities Calendar/Packet, monthly Menu for Cycles #1, #2, #3, #4; Photographs of Catered Meals.

Regarding Allegation #1 this investigation revealed that the facility had catered all their meals and snacks, effective March 2020 thru October 2022 due to the situation surrounding the COVID-19 disease. LPA/RA Ceniceros toured the commercial-size kitchen and observed today's dinner meal being prepared - which included: spaghetti and meatballs, tossed-green salad, garlic bread, fruit, dessert, and coffee/juice/water. Interviews conducted with C2 - C3 corroborated that they are offered three (3) meals a day and two (2) snacks per day. Administrator stated that when the clients are in attendance at their adult day program (Monday thru Friday 7:00 a.m. to 3:00 p.m.), breakfast and lunch is served at program. Clients confirmed that they enjoyed the catered food and meals provided at the facility. Staff members interviewed confirmed that the clients are offered three (3) meals per day and two (2) snacks per day and have not received complaints regarding the food not being of quality or quantity. LPA/RA Ceniceros observed a sufficient food supply of 7-days of perishables and non-perishables to meet the needs of 25 clients. LPA/RA also observed photographs of the catered meals delivered from a company called Health Guard which is a participant of the Mayfair Adult Daycare Program.

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of FOOD SERVICE: Facility is not providing food of the quality or quantity necessary to meet client's needs is found to be UNSUBSTANTIATED.

Regarding Allegation #2: this investigation revealed based on interviews conducted corroborated that Client #1 has a Conservator appointed by the L.A. County Superior Court of California, effective 07/21/16. A review of the client's court documents named Client #1's father as the power of attorney; therefore, no other next of kin was named in the client's facility records as a responsible or contact person. A review of Client #1's Identification and Emergency Information (dated 02/05/15) documented the person responsible to be the next of kin: Father. Administrator confirmed that once Client #1 had an appointee of Conservator it became the payee for the client; however, the facility did maintain the client's P & I funds. (LPA/RA Ceniceros reviewed Client #1's safeguarded cash resources for the year of 2021/2022 until C1 moved out on 04/01/22.
NAME OF LICENSING PROGRAM MANAGER: Araceli Ramirez
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Ceniceros
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20210716091112
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/21/2022
NARRATIVE
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Based on the evidence gathered and interviews conducted and records reviewed, although the allegationmay have happened or is valid, there is not a preponderance of evidence to prove the alleged violationdid or did not occur; therefore, the allegation of REPORTING REQUIREMENTS: Licensee did not ensure that communications to the facility from client's relatives were answered promptly and completely is found to be UNSUBSTANTIATED.

Regarding Allegation #3: this investigation revealed that during the COVID pandemic, facility staff would prepare packets for the clients to conduct activities. Facility staff also provided the clients with puzzles, movies, card games, and board games in an effort to meet the social distancing demands of COVID. Interviews conducted of clients corroborated that the facility were providing planned activities for the clients. Facility staff members interviewed corroborated that they did not receive complaints from the clients regarding facility not ensuring planned activities were provided to the clients. LPA/RA Ceniceros reviewed and obtained copies of the facility's activities calendar/packet.

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of OTHER: Licensee did not ensure that planned recreational activities were provided for the clients is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report was provided to the Administrator Christina Haddadin.

NAME OF LICENSING PROGRAM MANAGER: Araceli Ramirez
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Ceniceros
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3