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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425817
Report Date: 09/06/2024
Date Signed: 09/06/2024 03:09:02 PM

Document Has Been Signed on 09/06/2024 03:09 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CRYSTAL DOWNS ARF, INC.FACILITY NUMBER:
336425817
ADMINISTRATOR/
DIRECTOR:		MOQUETE JR., WILLIAMFACILITY TYPE:
735
ADDRESS:1897 CRYSTAL DOWNS DR.TELEPHONE:
(951) 738-0637
CITY:CORONASTATE: CAZIP CODE:
92883
CAPACITY: 4CENSUS: 2DATE:
09/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:39 PM
MET WITH:Administrator William MoqueteTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
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On 09/06/2024 at 12:39PM, Licensing Program Analysts (LPA's) Renese Howell-Small and Magda Malcore conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection to the facility. LPAs Small and Malcore were greeted by William Moquete, Administrator and Jose Moquete, Assistant Administrator and gained access to the home. Licensee/Administrator William Moquete opened the door for LPA's. LPAs Small and Malcore explained the purpose of the visit to Licensee/Administrator Moquete.

The facility has five (5) bedrooms, three (3) bathrooms, kitchen, dining room, living room, attached three car garage,and backyard. The facility is vendorized by Inland Regional Center (IRC). LPA's Small and Malcore completed a walk through of the facility, review of records, and medications audit.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPAs Small and Malcore observed two (2) clients during the visit. Two out of two (2 of 2) clients arrived at the facility during the visit. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 75 degrees Fahrenheit. LPA's Small and Malcore inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPAs Small and Malcore inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 105 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide detectors, charged fire extinguisher, and first aid kit with first aid book.

Posters such as; the personal rights, CCLD complaint poster, labor laws, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. LPA's Small and Malcore observed night lights in the hallway leading to clients' shared bathrooms. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.
*** Continuation in LIC809C ***

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2024
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CRYSTAL DOWNS ARF, INC.
FACILITY NUMBER: 336425817
VISIT DATE: 09/06/2024
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LPA Small audited two of two (2 of 2) clients’ medications and no issues were observed. LPA's Small and Malcore audited two of two (2 of 2) client's Personal and Incidental (P&I) and the Administrator was advised to use specific details on the Personal and Incidental log when gift cards are received for clients.

Yards/Outside: One shaded patio, one side gate with self-latching handle on the right side of the house that leads into the backyard, attached three (3) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPA's Small and Malcore observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPAs Small and Malcore reviewed two of two (2 of 2) client files for admission agreements, medical assessments/physician reports, Individual Program Plan (IPP) and P & I. LPA's Small and Malcore observed files reviewed were complete. LPA's Small and Malcore also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPA's Small and Malcore observed staff/Administrator files to be complete.

An exit interview was conducted where this report LIC809, LIC809C, and (Appeal Rights) were discussed, and copies were provided to Licensee/Administrator Moquete. Based upon record review, observations and interviews, there are no deficiencies at this time.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC809 (FAS) - (06/04)
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