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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005379
Report Date: 02/15/2024
Date Signed: 02/15/2024 03:59:40 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/15/2024 03:59 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:CRYSTAL COVE CARE #1FACILITY NUMBER:
306005379
ADMINISTRATOR:CALISHER, ERICFACILITY TYPE:
740
ADDRESS:18600 LOS LEONES STTELEPHONE:
(714) 593-2687
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 5DATE:
02/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:07 PM
MET WITH:Mel Rodriguez, House Manager TIME COMPLETED:
04:10 PM
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On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required Annual inspection. LPA was greeted and granted entry into the facility by Caregiver 1 (CG1) and met with House Manager (HM) Mel Rodriguez and discussed purpose of the visit. LPA Quiroz called Administrator (AD) Eric Calisher via telephone and explained the nature of the visit.

This facility is licensed to provide services to age range 60 and over, capacity of 6 which 1 can be bedridden, Hospice waiver approved for 4(four) hospice residents . There are five (5) residents in care of which (0) zero residents are receiving hospice care services. Administrator Eric Calisher has an Administrator Certificate with expiration date of 8/9/2025.

LPA Rosie Quiroz along with (HM) Rodriguez toured the interior and exterior of the facility. During today's inspection tour, LPA Quiroz observed three of four residents in the living room with staff supervision and 1 of four residents in their room resting. LPA Quiroz interacted and interviewed with staff, visitor and residents during today's visit.

LPA Quiroz inspected resident's bedrooms and bathrooms. Water temperatures were recorded to be between 108.5-109.8 degrees Fahrenheit. LPA Quiroz inspected resident’s bedrooms and appeared to be clean. Facility temperature in resident's bedrooms and throughout the facility was recorded to be within normal limits. LPA Quiroz observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food, water and PPE in garage area readily available for staff and residents. LPA Quiroz toured the outside of the facility and observed seating and shaded area backyard for residents and visitor's enjoyment in backyard area.

During today's visit, LPA Quiroz provided Consultation on Title 22 and Infection control.

An exit interview was conducted with (AD) Calisher via telephone and a copy of this report, LIC 811-Confidential names were provided to facility staff at exit.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
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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