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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004294
Report Date: 04/01/2022
Date Signed: 04/01/2022 02:43:31 PM

Document Has Been Signed on 04/01/2022 02:43 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:
04/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:03 PM
MET WITH:Caregiver Gerry Garino / Administrator Jon Castro TIME COMPLETED:
02:21 PM
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Licensing Program Analysts (LPAs) Andrea Mendivil and Sean Haddad conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPAs were greeted and granted entry into the facility by Caregiver Gerry Garino and explained the reason for the visit. Administrator Jon Castro arrived during the visit.

At 1:03 PM, LPAs toured the facility with Caregiver Gerry Garino. Facility is a single story home with 1 staff bedroom and 6 client bedrooms. Facility has 5 clients present during today's visit. LPAs observed clients relaxing in the facility. Facility appears clean and sanitary. All client rooms had the required elements as well as restrooms stocked with soap/ sanitizer. LPAs observed the screening/ sanitizing station in the entrance of the facility. Facility uses a handwritten sign in/ questionnaire. Facility takes client and staff temperatures daily and documents. Facility has covid precaution postings as well as all required department postings. The facility mitigation plan has been completed and approved. LPAs observed first aid kit. First aid kit contained all required items. LPAs observed locked medication drawer. Fire extinguisher is mounted and charged. LPAs toured the outside grounds and observed outside shaded visitation area. Exit gate is unlocked and self latching. LPAs observed the posted activity schedule including exercise, movies and bingo. Facility has a plan for covid testing clients and staff as needed as well as a plan for isolation. LPAs observed an ample supply of PPE. All staff and clients are vaccinated for Covid-19. LPAs reviewed all client files and all contained required documentation including updated emergency information and current physician reports.


No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2022
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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