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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004294
Report Date: 04/03/2024
Date Signed: 04/03/2024 05:57:48 PM

Document Has Been Signed on 04/03/2024 05:57 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:
ADMINISTRATOR/
DIRECTOR:
JON CASTROFACILITY TYPE:
735
ADDRESS:2525 E. HILDA PLACETELEPHONE:
(714) 774-6587
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY: 6CENSUS: 6DATE:
04/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
TIME VISIT/
INSPECTION BEGAN:
03:10 PM
MET WITH:Jon Castro - Administrator TIME COMPLETED:
TIME VISIT/
INSPECTION COMPLETED:
06:10 PM
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Licensing Program Analysts (LPA) Jerome Haley and Edward Kim made an unannounced visit for the purpose of conducting a required one year annual inspection. LPAs were greeted and granted entry by staff and explained the reason for the visit. Staff contacted Administrator Jon Castro who arrived later and was present for the remainder of the of the visit.

During the inspection, client bedrooms and bathrooms were observed. All client bedrooms had the necessary elements and were in compliance with regulation guidelines. Client bathrooms were clean and organized. Hot water temperatures were measured in the range of 108.1 degrees Fahrenheit and 112.2 degrees Fahrenheit. No hazardous items were observed in the client bathrooms, and all grab bars were tightly secured to the wall.

Near the front door is a locked closet used to store client medication, client and staff files, and an extra supply of hygiene items. Client P&I funds are kept in a locked box in the staff room.

In the kitchen knives and sharp objects are kept locked in a drawer. A perishable food supply that meets regulation requirements was observed in the refrigerator. A non-perishable food supply that meets regulation requirements was observed in the cabinets.

The garage was organized and free of clutter. Bikes and exercise equipment was observed in the garage. Emergency bags for the clients with emergency food and water inside the bags were observed hanging on the wall. A washer and dryer with a locked cabinet above with hazardous chemicals was observed, and an additional refrigerator with an additional supply of non-perishable food items.

The backyard was clean, organized, and walkways were free of obstruction. A shaded patio area with a table and chairs was observed. The side exit gate is self-closing and self-latching.

Continued on LIC809C

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
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 HOME
FACILITY NUMBER: 306004294
VISIT DATE: 04/03/2024
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Smoke detector/carbon monoxide detectors tested operational. A fully charged fire extinguisher was observed mounted on the wall in the kitchen.

An emergency evacuation drill was conducted March 5, 2024. Evacuation drills are conducted monthly for staff on each shift.

No deficiencies are being cited as a result of today’s visit.

An exit interview conducted, and a copy of this report was provided to Administrator Jon Castro.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC809 (FAS) - (06/04)
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