336426289-2-28-2025-18-AS-SJEN-DEBRD8-20250228115531

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336426289
Report Date: 02/28/2025
Date Signed: 02/28/2025 11:56:49 AM

Document Has Been Signed on 02/28/2025 11:56 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	CRYSTAL SPRINGS SENIOR CARE FACILITY		FACILITY NUMBER:	336426289
ADMINISTRATOR/ DIRECTOR:	NUNEZ, NELLY		FACILITY TYPE:	740
ADDRESS:	41747 WHITTIER AVENUE		TELEPHONE:	(951) 658-4817
CITY:	HEMET	STATE: CA	ZIP CODE:	92544
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	02/28/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	Nelly Nunez, Licensee		TIME VISIT/ INSPECTION COMPLETED:	12:10 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced annual required visit. Upon entry, LPA was greeted by Nelly Nunez, Licensee, and informed them of the purpose of the visit. At the time of the visit, there were one (1) staff member and six (6) residents present.

Facility Overview: The facility is a one-story home with six (6) bedrooms and two (2) bathrooms. There are no pools or known firearms on the premises.

Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements.

Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. The outdoor area was free of hazards. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked and inaccessible to residents. Both the smoke detector and carbon monoxide detector were operational, and the hot water temperature was 116°F. Fully charged fire extinguisher with new purchase receipt from October 18, 2024 is located at dining area.

Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods.

Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate. Continued on LIC809-C....

Rikesha Stamps	TELEPHONE: (951) 212-0616
Seo Jeon	TELEPHONE: 951-248-0309
	DATE: 02/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CRYSTAL SPRINGS SENIOR CARE FACILITY	FACILITY NUMBER: 336426289
	VISIT DATE: 02/28/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Record Review and Resident/Staff Files: LPA reviewed files for five (5) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Six (6) resident files were reviewed and contained all required documentation.

Health-Related Services/Incidental Medical Services: All resident medications were securely locked. LPA reviewed medications for two (2) residents, confirming that all medications were listed on the Medication Administration Record (MAR) and accounted for.

Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 1-16-2025, but Licensee did not have any log for the previous quarterly drill. A citation is issued. All facility exits were clear of obstructions.

One deficiency was cited during the visit. An exit interview was conducted, during which this report was reviewed and provided along with LIC809-D and appeal rights.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo Jeon	TELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 02/28/2025 11:56 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CRYSTAL SPRINGS SENIOR CARE FACILITY	FACILITY NUMBER: 336426289
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and staff interviews, the licensee did not comply with the section cited above which posed a potential health and safety risk to persons in care.
	POC Due Date: 03/07/2025
	Plan of Correction
1 2 3 4	Licensee will send copies of fire/earthquake log from the previous quarter by email.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Rikesha Stamps	TELEPHONE: (951) 212-0616
Seo Jeon	TELEPHONE: 951-248-0309
	DATE: 02/28/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3