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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604719
Report Date: 08/07/2024
Date Signed: 08/07/2024 10:57:01 AM

Document Has Been Signed on 08/07/2024 10:57 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
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:
08/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:48 AM
MET WITH:Deseray Sandoval, Staff
& Sally Saif Administrator		TIME VISIT/
INSPECTION COMPLETED:
11:04 AM
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Case Management visit. LPA identified themselves to the Deseray Sandoval, Staff
and we discussed the purpose of the visit. Sally Saif, Administrator arrived during the visit.

Today's visit is in response to the AWOL of Client 1 (C1) date of incident: August 3, 2024. The facility properly reported C1 going AWOL. The facility's Missing Persons/Absentee Notification Plan was reviewed on this date with the Licensee. C1 was away from the facility for about 10 minutes unsupervised and was returned safely to the facility by staff. Staff found C1 down the street with an unidentified male and they walked C1 back to the facility. C1 requested an ambulance and PERT and so the staff called PERT and they were the ones that took C1 to the hospital. C1 went to the hospital for one day and returned on Sunday. C1 went to program on Monday and told all of the staff what they did while they were AWOL. LPA conducted interviews on this date. According to C1s latest physicians report dated 07/03/2024 it states the client can leave the facility unassisted. LPA received copies of pertinent information regarding C1.

No deficiencies were cited or observed on this date.

An exit interview was conducted with the Administrator. A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) was provided to Saif at the conclusion of the visit.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
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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