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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004294
Report Date: 04/05/2023
Date Signed: 04/05/2023 02:51:29 PM

Document Has Been Signed on 04/05/2023 02:51 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:
04/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Alfredo GarciaTIME COMPLETED:
03:00 PM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analysts (LPAs) Sean Haddad and Dwayne Mason for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20230113171948. LPAs met with Staff #1 (S1) Alfredo Garcia and explained the reason for today’s inspection. Administrator (AD) Jon Neil Castro was not present during the inspection.

During the course of the investigation, LPAs attempted to inspect client money and ledgers for 6 clients, but the key to access the client money was not present at the facility and S1 and Staff #2 (S2) Gerry Garino confirmed the key was with S2 who is not at the facility today.

Based on the information obtained 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: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2023
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 04/05/2023 02:51 PM - It Cannot Be Edited


Created By: Sean Haddad On 04/05/2023 at 02:40 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: 04/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/06/2023
Section Cited
CCR
85072(b)(7)

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85072 Personal Rights … (b) each client is accorded the following personal rights: … (7) To possess and control his/her own cash resources. This requirement was not met as evidenced by:
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Licensee stated they will create a new protocol for making sure the key to access client cash resources is always present at the facility, train staff on the new protocol, and submit proof to LPA by POC due date.
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Based on observations and interviews, the licensee did not ensure 6 out of 6 clients had possession and control of their own cash resources as the key to access the cash resources was not present at the facility, which poses an immediate personal rights risk to clients 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: 04/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2023


LIC809 (FAS) - (06/04)
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