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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004294
Report Date: 04/29/2024
Date Signed: 04/30/2024 06:57:42 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
04/18/2024 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240418171209
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:
04/29/2024
UNANNOUNCEDTIME BEGAN:
09:37 AM
MET WITH:Jon Castro- Licensee/AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Facility is in disrepair.
Food is not properly stored.
Cleaning supplies stored in areas accessible to clients.
Clients are not provided a comfortable environment.
Clients are not provided proper hygiene items.
Facility is not clean.
INVESTIGATION FINDINGS:
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[The LIC9099s were AMENDED]
Licensing Program Analyst (LPA) Jessica Cho made an unannounced subsequent visit for the purpose of delivering the findings into the above allegations. LPA was greeted and granted entry by Lead Staff Gerry Garino and explained the purpose of the visit. Licensee/Administrator Jon Castro arrived at 10:15am and was advised of the visit and the allegations.

On April 23, 2024, from 12:15pm-3:30pm, LPAs Cho and Edward Kim initiated the complaint investigation. During the course of the initial visit, LPAs toured the facility, interviewed clients/staff, and obtained copies of facility/client records which includes the Resident Roster, Personnel Report, Staff Weekly Schedule, Face Sheets, Individual Program Plans (IPPs), Physician Reports for all clients, and additional pertinent documentation. During today's visit, LPA inspected the back bathroom and the private staff bathroom.

Regarding the allegation, facility is in disrepair, [CONTINUED ON LIC9099C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024
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 7
Control Number 22-AS-20240418171209
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: KRYSTAL ADULT RESIDENTAL CARE HOME
FACILITY NUMBER: 306004294
VISIT DATE: 04/29/2024
NARRATIVE
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the witness observed furniture placed in and around the house resulting in clutter including the tabletop removed and placed to the side, couch with a missing cushion, the furniture and flooring in poor condition, the awning over the front door rotting and falling apart, the side exit gate rotting and falling of its hinges, and a crack in the back bathroom window. During the initial visit, LPAs did not observe a bucket below the kitchen sink pipe, and the Administrator was advised to repair the side exit gate again due to the self-latching mechanism not operating. The exit was observed to be self-latching during today's visit.

Regarding the allegation, food is not properly stored, the witness observed two dozen eggs stored in the pantry unrefrigerated and an opened package of frozen meat.

Regarding the allegation, cleaning supplies stored in areas accessible to clients, witness observed two unmarked or unlabeled bottles of chemicals sitting in a bucket. During the initial visit, LPAs observed a bottle of Fabuloso hidden behind the yellow mop bucket adjacent to the laundry machine and four additional bottles of cleaning solutions unsecured in a bucket in the garage. The items were removed and secured in a locked cabinet during the visit.

Regarding the allegation, clients are not provided a comfortable environment, the witness observed the facility to be unorganized, in disarray, and disrepair evidenced by the physical environment.

Regarding the allegation, clients are not provided proper hygiene items, the witness observed bath towels were thin with holes and the toothbrushes were in poor condition. During the inspection conducted by LPAs, the toothbrushes were observed needing a replacement for two out of the six clients.

Regarding the allegation, facility is not clean, the witness observed mold in the bathroom. LPAs observed during the visit at 12:53pm and during today's visit at 9:40am that the staff private bathroom also utilized by the clients had signs of mold on the walls.

Based on the observations and the records that were reviewed, the preponderance of evidence standard has been met, therefore the aforementioned allegations are deemed SUBSTANTIATED as per the Title 22, Division 6, Chapter 1 of the California Code of Regulations. Deficiencies are being cited on the attached LIC 9099Ds. An exit interview was conducted with Licensee/Administrator Jon Castro, and a copy of this report along with the LIC9099-Cs, LIC9099-Ds, and the appeal rights were provided at exit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 22-AS-20240418171209
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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: 04/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
CCR
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Type A
04/30/2024
Section Cited
CCR
80087(g)
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80087 Building and Grounds (g) Disinfectants, cleaning solutions…., and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by:
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Based on observations, disinfectants and cleaning solutions were observed unsecured in the garage which poses an immediate risk to the Health, Safety, and Personal Rights risk to persons in care. This was corrected during the visit.
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Administrator stated that they will provide an in-service training and will submit proof of training as well as an Acknowledgement of Understanding for the said deficiency to LPA via email by POC due 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.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 22-AS-20240418171209
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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: 04/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/10/2024
Section Cited
CCR
80076(a)(1)
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80076 Food Services (a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality… stored, prepared and served in a safe and healthful manner.
This requirement was not met as evidenced by:
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Administrator stated that they will provide an in-service training regarding food services and submit proof of training as well as an Acknowledgement of Understanding for the said deficiency to LPA via email by POC due date.
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Based on observation, the eggs and meat were unrefrigerated which poses a potential risk to the Health, Safety, and Personal Rights risk to persons in care.
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Type B
05/10/2024
Section Cited
CCR
80072(a)(2)
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80072 Personal Rights (a) …each client shall have personal rights which include, but are not limited to… (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.This requirement was not met as evidenced by:
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Administrator stated that they will ensure facility is organized and free of clutter moving forward and will review and submit an Acknowledgement of Understanding for the said deficiency to LPA via email by POC due date.
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Based on observations, the witness observed the facility did not meet the section cited above regarding clutter/quality of the furniture which poses a potential Health, Safety, or 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: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 22-AS-20240418171209
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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: 04/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/10/2024
Section Cited
CCR
85088(c)
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85088 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.
This requirement was not met as evidenced by:
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Administrator stated that the toothbrushes for two out of the six clients will be replaced, and the proof of correction will be submitted to LPA via email by POC due date.
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Based on the observations of the witness, the towels were thin with holes and the toothbrushes were in poor condition which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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Type B
05/10/2024
Section Cited
CCR
80087(a)
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80087 Building 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 was not met as evidenced by:
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Administrator stated that they will address the mold and repair the side exit gate to ensure it is self-latching and will provide proof of corrections via email by POC due date. Please replace the flooring and provide the POC by 10/31/24.
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Based on observations, mold was present in the staff bathroom on separate occasions and facility was not in good repair which poses a potential risk to the 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: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7