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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426126
Report Date: 05/27/2022
Date Signed: 05/27/2022 03:06:21 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/29/2022 and conducted by Evaluator Javier Prieto
COMPLAINT CONTROL NUMBER: 56-AS-20220429133816
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:8CENSUS: DATE:
05/27/2022
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Breeana RedwineTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not provide a refund upon resident’s death.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conclude a complaint investigation regarding an allegation that the facility did not provide a refund upon resident’s death. LPA met with staff Breeana Redwine. LPA interviewed licensee Kamal Ebadpour and witness. Interviews concluded that a refund was provided. It was later negotiated for a sum that both facility representative and witness agreed upon.

Based on the information obtained there is not enough evidence that the facility did not provide a refund upon resident’s death. Therefore, the allegations is deemed UNSUBSTANTIATED at this time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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