<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004294
Report Date: 04/23/2024
Date Signed: 04/23/2024 03:58:08 PM

Document Has Been Signed on 04/23/2024 03:58 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:KRYSTAL ADULT RESIDENTAL CARE HOMEFACILITY NUMBER:
306004294
ADMINISTRATOR/
DIRECTOR:		JON CASTROFACILITY TYPE:
735
ADDRESS:2525 E. HILDA PLACETELEPHONE:
(714) 774-6587
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY: 6CENSUS: 6DATE:
04/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Jon Castro- Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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
Licensing Program Analysts (LPAs) Jessica Cho and Edward Kim continued the visit after continuing the investigation into Complaint Control Number: 22-AS-20240418171209. LPAs stated the purpose of the visit to Licensee/Administrator Jon Castro. LPAs observed Staff #1 (S1) was not associated per the Licensing Information System (LIS) dated April 22, 2024 and the Guardian Employee Roster dated April 23, 2024 at 2:12pm as required per the Criminal Record Clearance of the Title 22 Regulations. S1 stated that he was employed in 1993. S1 was associated during the visit.

A deficiency is being cited as per the Title 22, Division 6, Chapter 1 of the California Code of Regulations. See the attached LIC809-D. An immediate civil penalty is being assessed. See the attached LIC421BG.

An exit interview was conducted with Licensee/Administrator Jon Castro, and a copy of this report including the LIC809D, LIC421BG, LIC811, and the appeal rights were provided at the end of the visit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 04/23/2024 03:58 PM - It Cannot Be Edited


Created By: Jessica Cho On 04/23/2024 at 03:36 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: 04/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/24/2024
Section Cited
CCR
80019(e)(3)

1
2
3
4
5
6
7
80019 Criminal Record Clearance "(e) All individuals subject to a criminal record review.... shall prior to working...in a licensed facility:
(3) Request a transfer of a criminal record clearance..." This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator Castro associated the staff during the visit and will submit an Acknowledgement of Understanding of the said deficiency to LPA via email by POC due date.
8
9
10
11
12
13
14
Based on observations and record review, S1 was not associated at the time of inspection which poses an immediate Health, Safety, and Personal Rights risk to persons 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:Lourdes Montoya
LICENSING EVALUATOR NAME:Jessica Cho
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2