198601791-3-24-2025-28-AS-WSHO-DFJS3V-20250408133144

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601791
Report Date: 03/24/2025
Date Signed: 03/24/2025 04:56:49 PM

Substantiated

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
03/17/2025 and conducted by Evaluator Nune Margaryan

COMPLAINT CONTROL NUMBER: 28-AS-20250317160017

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: 19	DATE:	03/24/2025
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	ChristinaHaddadin		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not prevent clients from engaging in a physical altercation.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analysts (LPA) Nune Margaryan conducted an unannounced initial 10-Day complaint investigation regarding the above allegation. LPA meet with Administrator who assisted with the visit. The purpose of the visit was explained.

The investigation consisted of the following: Obtained copies of Staff & Clients Rosters, interviewed Administrator, Staff 1(S1) - Staff 3 (S3), Client 2 (C2) - Client 4 (C4), LPAs also reviewed C1's and C2's files and obtained the copies of relevant documents. LPA was not able to interviewe C1 because C1 was under the custody at the time of visit.

Continue 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025

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-20250317160017

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: 03/24/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Regarding the allegation: Staff did not prevent clients from engaging in a physical altercation. On 03/16/25 C1 went up to C2 and beat / hit C2 while they are smoking in the smoking area outside of facility. There were no other clients or staff present during the incident. Interviewed Administrator, S1 and S2 stated that at 6:00 am S1 was doing rounds and noticed that C1 was not at the facility and had not checked out with staff. C2 was in their room sleeping under their blanked. At 7:00 am when medication was given, C2 was still in the bed and staff noticed that C2 has a black eye and bloody nose. Staff called 911 and C2 was taken to the hospital for evaluation. At 9:00 am C1 was returned and asked for medical attention for their hand. C1 stated that C1 punched C2. 911 was called. C1 was transported to be cleared medically but charged with assault. C2 came back around 9:00pm. Hospital release C2, because C2 refuses medical attention. As of today C1 didn't came back. C1 is being held in custody until 04/02/25. Interviewed Administrator, S1 and S2 stated that incident happened around 5:30am. S1 and S2 stated that C1 and C2 were smoking in the smoking area and C1 hit C2. S1 and S2 stated they didn't see how it happened. Interviewed S4 stated that they heard about altercation between C1 and C2, but don't have detailed information about the incident. Interviewed C2 stated that C1 hit them, and they went to the hospital. C1 punch on their face, nose and stomach. Interviewed C3, C4 and C5 stated that they heard about incident but didn't witness how it happened. LPA was not able to review video surveillance, because surveillance system where the cloud storage formats every 7 days to clear storage space. Based on file review LPA observed that C1 has history of hitting and aggression. Staff shall provide care and supervision necessary if it is known that client(s) engage in a physical altercation while they are in the same area. Even though Administrator and staff stated that there are always 2-3 staff at the facility there were no staff to supervise the clients at the time of incident and prevent clients from engaging in a physical altercation.

Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be Substantiated.

Deficiency is cited. See LIC 9099D.

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

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20250317160017

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/24/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/01/2025 Section Cited CCR 80078(a)	1 2 3 4 5 6 7	80078 Responsibility for Providing Care and Supervision.(a) The licensee shall provide care and supervision as necessary to meet the client's needs.	1 2 3 4 5 6 7	The administrator shall ensure that all adequate care and supervision will be provided by all staff to the clients. The administrator will retrain staff on providing adequate supervision and will submit a copy of singning in sheet for all staff that recieved in-service training by the POC due date.
	8 9 10 11 12 13 14	Based on interviews conducted and file reviews, on 03/16/25, C2 was punched in the face, nose and stomach by C1, which could have been prevented by the staff. This poses a potential health and safety risk to clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3