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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004294
Report Date: 04/20/2023
Date Signed: 04/20/2023 03:39:49 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/10/2023 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230410145220
FACILITY NAME:KRYSTAL ADULT RESIDENTAL CARE HOMEFACILITY NUMBER:
306004294
ADMINISTRATOR:JON CASTROFACILITY TYPE:
735
ADDRESS:2525 E. HILDA PLACETELEPHONE:
(714) 774-6587
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY:6CENSUS: 6DATE:
04/20/2023
UNANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:Alfredo GarciaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility is falsifying personnel records
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit for the purpose to conduct a complaint investigation into the above allegation. LPA was greeted and granted entry by Care Staff Alfredo Garcia. LPA observed a total of three staff on duty providing care to six clients. At 10:44am, Staff Garcia notified Administrator (Admin) Jon Castro of the visit. LPA made contact with the Administrator and stated the purpose of the visit and received verbal consent permitting Staff Garcia to sign this report on his behalf. During the course of the investigation, LPA obtained and reviewed copies of eleven staff records, and conducted an interview with Administrator Castro. The following was determined:

It was alleged that the facility is falsifying personnel records. Upon review of eleven staff records, LPA contacted the Crisis Prevention Institute, Inc. (CPI). LPA observed that on the Nonviolent Crisis Intervention Certificate by CPI, ten out of eleven staff were trained by Instructor 1 (I1). LPA verified I1 is recognized by CPI. One out of the eleven staff was trained by Instructor 2 (I2) who was not recognized by CPI due to the certification of I2 expiring in August 2013.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
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 22-AS-20230410145220
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: KRYSTAL ADULT RESIDENTAL CARE HOME
FACILITY NUMBER: 306004294
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/21/2023
Section Cited
HSC
1550(c)
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The department may.. or suspend or revoke) any license of subdivision (b) of Section 1524 for any of the following grounds: (c) Conduct which is inimical to the health, morals, welfare, or safety of either the people of this state or an individual in, or receiving services from, the facility or certified family home.
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Licensee to review and to forward an Acknowlegement of Understanding of the said regulation to LPA via email by POC due date.
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This requirement is not met as evidenced by: Based on observation, interviews, and record review, LPA received a false CPI training certificate not recognized by CPI which poses an immediate Health, Safety, and Personal Rights risk to persons in care.
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Type B
04/27/2023
Section Cited
CCR
80075(f)
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80075 Health Related Services (f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
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Licensee to ensure three staff complete the First Aid/CPR/AED coursework and to submit a current copy of the certifcate; in addition to verifying the validity of the certificate for one staff and to provide proof to LPA via email by POC due date.
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Based on observation, interviews, and record review, First Aid/CPR/AED training certificates for three out of eleven staff were invalid and one out of eleven did not have a certificate by a qualified agency which poses a potential Health, Safety, and Personal Rights risk to persons in care.
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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.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20230410145220
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: KRYSTAL ADULT RESIDENTAL CARE HOME
FACILITY NUMBER: 306004294
VISIT DATE: 04/20/2023
NARRATIVE
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The in-authentication of the certificate voids the 12 training hours for S1. In addition to the CPI certifications, LPA contacted the American Red Cross to verify the validity of eleven First Aid/CPR/AED Training certificates. LPA verified via the customer service representative that the certificates for three out of eleven staff were not current and one out of the eleven did not have have the name of the organization issuing the certificate which makes it invalid.

Based on the observations, interviews, and the records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is deemed SUBSTANTIATED. A deficiency is being cited per Title 22, Division 6 of the California Code of Regulations. See LIC9099D.

An exit interview was conducted with Care Staff Alfredo Garcia, and a copy of this report along with the LIC9099C, LIC811s, LIC9099D, and the appeal rights were provided during this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3