366426126-3-28-2024-56-AS-AFAL-D3STD5-20240328143746

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366426126
Report Date: 03/28/2024
Date Signed: 03/28/2024 02:38:04 PM

Document Has Been Signed on 03/28/2024 02:38 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	CRYSTAL GARDEN RCFE		FACILITY NUMBER:	366426126
ADMINISTRATOR:	EBADPOUR, KAMAL		FACILITY TYPE:	740
ADDRESS:	13224 IROQUOIS		TELEPHONE:	(760) 503-9180
CITY:	APPLE VALLEY	STATE: CA	ZIP CODE:	92308
CAPACITY:	10	CENSUS: 10	DATE:	03/28/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:53 AM
MET WITH:	Breanna Redwine, Administrator		TIME COMPLETED:	02:40 PM

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Licensing Program Analyst (LPA) Anna Fannell conducted an unannounced visit to this facility for a required annual inspection. Entry into the facility is unobstructed and LPA met with administrator Breanna Redwine. The facility is approved for a Hospice Waiver for six (6) residents. LPA and ADministrator toured the interior and exterior of the facility.

Physical Plant: The facility is operating within capacity and not beyond the conditions of the license. There are no pools or other bodies of water located on the premises. The facility is being maintained at a comfortable temperature for residents. All passageways are kept free of obstruction. Hot water temperature was measured in all bathrooms and measured between 105 and 110 degrees Fahrenheit. Grab bars, textured shower floor, and shower aid equipment are utilized by residents. Fire safety installations such as extinguishers, sprinklers, and alarms are present. Fire extinguishers were observed to be charged and last inspected on 08/04/2023. A hallway smoke detector was tested by facility staff and all other units, including bedrooms, were found to be interconnected and working. Overall the facility is in good condition; it is clean, sanitary and free of foul odors.

Kitchen and Food Service: LPA was present during lunch service. The total daily diet provided to residents appears to be of the quality and in the quantity necessary to meet resident needs. There is at least a one week supply of nonperishable foods and two days of perishable food items, which meets regulatory requirements. All readily perishable food or beverages capable of micro-organism growth are being stored in covered containers at appropriate temperatures. Sharps and cleaning agents are kept secured in the kitchen.

Medication, Care, and Supervision: The facility has sufficient and competent staff to provide services needed to meet resident needs. Chemicals and items which can constitute a danger are stored inaccessible to residents. LPA inspected medications and found them in their original containers. Medications appear to be dispensed according to the physician's orders.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Fannell	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: CRYSTAL GARDEN RCFE	FACILITY NUMBER: 366426126
	VISIT DATE: 03/28/2024

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Resident and Staff Files: LPA reviewed all staff and resident files. Resident files had the required documentation including admission's agreement, consent forms, and appraisal and/or needs and services plan. Staff files had the required documentation including mandated reporting, health screening report, CPR certification. LPA Fannell did not observe updated training related to hospice care and dementia care. These pose potential health and safety risks to residents in care.

Operations and Administration: Disaster Plan is present and Administrator Redwine will be updating the plan as needed. Administrator is present in the facility a sufficient amount of hours and their administrator certification is up to date. The required ombudsman poster is posted and Administrator posted licensing poster in public view. Residents rights are posted and a copy is kept the resident's file.

Refer to LIC809D for deficiencies were cited during this visit. Technical advisories and violations were issued in relation to deficiencies observed. An exit interview was conducted where this report, LIC 809D, and appeal rights were discussed and provided to Administrator Redwine.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Fannell	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/28/2024 02:38 PM - 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CRYSTAL GARDEN RCFE	FACILITY NUMBER: 366426126
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87633(b)(6)(B)

Hospice Care for Terminally Ill Residents

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee's responsibilities for implementation of the hospice care plan. (B) The hospice agency will provide training specific to the current and ongoing needs of the individual resident receiving hospice care and that training must be completed before hospice care to the resident begins. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations and records review, the licensee did not comply with the section cited as LPA did not observe staff training related hospice care needs which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/22/2024
	Plan of Correction
1 2 3 4	Licensee shall conduct training for hospice related care for all staff providing care. Licensee shall provide proof of training no later than end of POC date.

Type B

Section Cited

CCR

87705(c)(3)(A)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: (A) Dementia care including, but not limited to, knowledge about hydration, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living; This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations and records review, the licensee did not comply with the section cited as LPA did not observe staff training related hospice care needs which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/22/2024
	Plan of Correction
1 2 3 4	Licensee shall conduct Dementia care training for all staff providing care. Licensee shall provide proof of training no later than end of POC date.

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

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Fannell	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

LIC809 (FAS) - (06/04)

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