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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004294
Report Date: 01/17/2023
Date Signed: 01/17/2023 04:00:25 PM

Document Has Been Signed on 01/17/2023 04:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 HOMEFACILITY NUMBER:
306004294
ADMINISTRATOR:JON CASTROFACILITY TYPE:
735
ADDRESS:2525 E. HILDA PLACETELEPHONE:
(714) 774-6587
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY: 6CENSUS: 6DATE:
01/17/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Gerry GarinoTIME COMPLETED:
04:15 PM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20230113171948. LPA met with Staff #1 (S1) Gerry Garino and explained the reason for today’s inspection.

During the course of the investigation, LPA observed all of the clothes of 2 residents stored in the locked garage and observed no clothes in these residents’ rooms. S1 stated that these residents change their clothes too often so the clothes were placed in the garage. During the inspection, S1 relocated the clothes to the residents’ rooms and LPA confirmed.

Based on the observations made during the investigation, violations are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/17/2023 04:00 PM - It Cannot Be Edited


Created By: Sean Haddad On 01/17/2023 at 03:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 01/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/18/2023
Section Cited
CCR
85072(b)(6)

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85072 Personal Rights. (b) ... (6) To possess and use his/her own personal items, including his/her own toilet articles. This requirement was not met as evidenced by:
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During the inspection, facility staff relocated the clothes to the residents’ rooms and LPA confirmed.

POC CLEARED
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Based on observations, the licensee did not ensure 2 residents had access to their clothes, which poses an immediate personal rights risk to residents 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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023


LIC809 (FAS) - (06/04)
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