198601791-9-12-2023-28-AS-WSHO-D2F54H-20240213183731

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601791
Report Date: 09/12/2023
Date Signed: 09/12/2023 03:18:25 PM

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
09/07/2023 and conducted by Evaluator Nune Margaryan

COMPLAINT CONTROL NUMBER: 28-AS-20230907133734

FACILITY NAME:	CRYSTAL MANOR RESIDENTIAL CARE HOME		FACILITY NUMBER:	198601791
ADMINISTRATOR:	CHRISTINA HADDADIN		FACILITY TYPE:	735
ADDRESS:	3406 BALDWIN PARK BOULEVARD		TELEPHONE:	(626) 337-1424
CITY:	BALDWIN PARK	STATE: CA	ZIP CODE:	91706
CAPACITY:	26	CENSUS: 23	DATE:	09/12/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Christina Haddadin		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff unlawfully charged SSI client

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced complaint investigation visit regarding the above allegation. LPA Margaryan met with Administrator and explained the reason for the visit.
The visit consisted of the following: LPA Margaryan obtained copies of staff/client roster, Client #1 (C1) Admission Agreement, SIR dated 08/05/23, MAR for the month of August 2023, copy of the invoice from construction company "Barraza", copy of letter faxed to SSI office and other relevant documents. LPA Margaryan tour the Client #1 (C1) room, interviewed Staff #1 (S1), Staff #2 (S2), Staff #3 (S3)., Client #2 (C2) and Clent #3 (C3) .Client #1 (C1) no longer lives at the facility. S2,C2 and C3 were interviewed over the phone.

Cont. 9099C

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230907133734

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: 09/12/2023

NARRATIVE

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*The purpose for amendment is to remove confidential information. Corrected information does not change the findings. LPA Nune Margaryan redelivered report on 02/12/24 and obtained the signature.

Investigation revealed the following: Regarding allegation, Staff unlawfully charged SSI client, it was alleged that C1 owes the facility $1700 for property damage by fault of the client (C1).
Based on interviews and documents reviewed (C1) was admitted to the facility on 08/03/2018 and left the facility on 08/05/2023. C1 didn’t notify Administrator or any other staff that C1 is leaving (On the Admission Agreement indicated that " Provide two weeks’ notice of intent to move from the facility unless the client's physical condition prevents this being done). S2 notified Administrator on 08/05/23 over the phone that it is time for C1 to take the medication, and C1 is not at the facility. S2 stated that C1 was at the facility until lunch time. C1 had lunch at the facility. S2 confirmed that C1 damaged the room, painted on the walls, painted on the cabinet door in the bathroom (pictures were provided to LPA by the administrator). LPA interviewed S3, who also confirmed that damages in the C1s room were done by C1. LPA interviewed C2 and C3. C2 stated that C1 left the facility about 3 weeks ago and doesn't have any other information. C3 stated that C1 destroyed and ruined the room. C3 stated that C1 left the facility 2-3 weeks ago.

LPA reviewed the documentation and observed that C1 owns the Facility $225 for 5 days staying at the facility in month of August 2023. The invoice from the contractor shows $1500 for all the repairs in C1s room. Administrator stated that lawyer put total amount of $1725.00 on the letter. Administrator asking for the money that C1 owe the facility for 5 days, which is $225.00. The administrator stated that it was confusing because the lawyer indicates the total amount in one invoice without breaking down the amount. For the amount of $1500.00 administrator will follow up with the lower based on promissory note signed by C1’s representative to fix / pay for any damages that will be done by C1.

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 is Unsubstantiated.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

LIC9099 (FAS) - (06/04)

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