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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426126
Report Date: 04/06/2023
Date Signed: 04/06/2023 11:29:24 AM


Document Has Been Signed on 04/06/2023 11:29 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, 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:8CENSUS: 5DATE:
04/06/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
10:44 AM
MET WITH:Kamal Ebadpour, LicenseeTIME COMPLETED:
11:35 AM
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On April 6, 2023 at 10:44 a.m., Licensing Program Analyst (LPA) Rayshaun Nickolas conducted an announced case management visit. The purpose for this case management visit is to approve the facility's request for a change of capacity. LPA met with Licensee Kamal Ebadpour who assisted LPA Nickolas with conducting a facility tour.

Per the LIC200, the licensee submitted a total capacity increase from eight (8) non-ambulatory to (10) non-ambulatory, specifically increasing the amount of bedridden from six (6) to eight (8) on July 21, 2022. A representative from the Apple Valley Fire Department conducted a fire safety inspection on March 21, 2023, and approved the change in status.

During today’s visit, LPA Nickolas toured the interior/exterior of the building and visually inspected the resident bedrooms and bathrooms. LPA Nickolas observed that bedrooms #1, #2, #3, # 4, and #5 have exits doors with ramps that access the outside of the facility. LPA Nickolas confirmed that all identified shared rooms are large enough to accommodate the required furniture for clients without inhibiting movement into and throughout the rooms. LPA Nickolas additionally confirmed that there are sufficient bathrooms in the facility to meet Title 22 requirements for ratio of clients to bathrooms.

The physical plant is ready for the capacity increase. LPA Nickolas has notified the Licensee of final capacity increase approval. LPA Nickolas further advised the Licensee that the new license will follow in the mail after capacity increase visit.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and a copy of this report will be emailed to Ebadpour due to technical difficulties.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023
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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