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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604719
Report Date: 06/25/2024
Date Signed: 06/25/2024 01:19:17 PM

Document Has Been Signed on 06/25/2024 01:19 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 DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:CRYSTAL CARE FACILITY INCFACILITY NUMBER:
374604719
ADMINISTRATOR/
DIRECTOR:		SAIF, SALLYFACILITY TYPE:
735
ADDRESS:9026 MAC LANETELEPHONE:
(248) 307-6966
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 4CENSUS: 2DATE:
06/25/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:08 AM
MET WITH:Raafat Azeez, Staff
& Sally Saif, Administrator		TIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced visit to conduct a post-licensing inspection to ensure that the facility is operating in compliance with California Code of Regulations, Title 22, Division 6. LPA was granted entry into the facility by Raafat Azeez, Staff. LPA Holmes disclosed the purpose of the visit. Sally Saif, administrator arrived during the visit.

A tour of the facility was conducted inside and out. LPA accompanied by Raafat Azeez, conducted a general overall inspection, which included, but was not limited to, the following: facility physical plant, food service, medication management, records review, and facility administration.

During today's inspection, LPA observed the following: All indoor and outdoor passageways were free from obstructions. The facility’s indoor temperature was comfortable, there is a mini split available that provides air conditioning. No pools or bodies of water were observed. According to the Licensee there are no firearms or ammunition stored in the facility. Cleaning supplies and toxins were locked and inaccessible to the residents. LPA toured resident bedrooms. The rooms had the required furnishings and sufficient lighting. A fireplace was observed, and is non-operational. Licensee provided the residents with clean linens, in good repair, and sufficient hygiene products for personal use. The facility had functioning carbon monoxide detectors and smoke detectors that met statutory regulations.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2024
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 DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: CRYSTAL CARE FACILITY INC
FACILITY NUMBER: 374604719
VISIT DATE: 06/25/2024
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The facility was stocked with a two (2) day supply of perishable and seven (7) day supply of nonperishable food items. Medications were stored in a locked cabinet and were labeled and maintained in compliance with label instructions. Staff present had criminal record clearance and current first aid certification on file. The resident files contained current records. Licensee does not currently secure resident cash resources. LPA observed the required postings in a prominent place in the facility. Administrator Certification for Sally Saif expires on 05/19/2025.

Based on today’s visit there were no deficiencies cited in the areas above. An exit interview was conducted with Saif and a copy of this report and Licensee/Appeal Rights (LIC9058 03/22) were provided to the Licensee at the conclusion of the visit.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024
LIC809 (FAS) - (06/04)
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