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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426289
Report Date: 04/01/2022
Date Signed: 04/01/2022 03:07:03 PM


Document Has Been Signed on 04/01/2022 03:07 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:CRYSTAL SPRINGS SENIOR CARE FACILITYFACILITY NUMBER:
336426289
ADMINISTRATOR:NUNEZ, NELLYFACILITY TYPE:
740
ADDRESS:41747 WHITTIER AVENUETELEPHONE:
(951) 658-4817
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:6CENSUS: 6DATE:
04/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:37 PM
MET WITH:Maria Lopez, CaretakerTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to conduct an annual inspection with an emphasis on infection control.

LPA met with Caretaker Lopez. Present in the facility during time of visit were 6 clients. There are currently no cases of COVID-19 within the facility. Licensee/Administrator Nelly Nunez arrived inside the facility during the visit.

During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures. LPA observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions as well as proper use of face coverings.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities. LPA later discussed infection control practices and procedures with Ms. Nunez.

An exit interview was conducted, and a copy of this report along with a copy of the report was discussed with and provided to Ms. Nunez.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
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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