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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426126
Report Date: 04/07/2021
Date Signed: 04/08/2021 01:12:25 PM

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 GARDEN RCFEFACILITY NUMBER:
366426126
ADMINISTRATOR:EBADPOUR, KAMALFACILITY TYPE:
740
ADDRESS:13224 IROQUOISTELEPHONE:
(760) 503-9180
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY:6CENSUS: 5DATE:
04/07/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Kamal EbadpourTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Stephanie Williams contacted the facility via video conferencing app due to the COVID-19 pandemic. The tele-visit was initiated at the licensee's request for a change of capacity. LPA conducted the tele-visit with Administrator, Kamal Ebadpour.

A fire clearance was granted by the Apple Valley Fire Department on 4/6/2021 for 8 non-ambulatory residents, of which 6 residents may be bedridden. The LPA virtually toured the facility and inspected all bedrooms. The Administrator stated that rooms #1, #2, and #5 were all shared rooms and rooms #3 and #4 were private rooms. During the tele-visit, LPA did not observe any health or safety concerns.

LPA will grant the change of capacity request. The Administrator was advised that a new license will be mailed to the facility address.

An exit interview was conducted where this report was discussed and a copy was provided via email to Ebadpour.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021
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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