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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604719
Report Date: 10/03/2024
Date Signed: 10/03/2024 03:43:17 PM

Document Has Been Signed on 10/03/2024 03:43 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:
10/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Sally Saif, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:19 AM
NARRATIVE
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility by Sally Saif, Administrator to whom LPA discussed the purpose of the visit.

According to the facility’s license, the facility has a maximum capacity of four (4) developmentally disabled adults, all ambulatory. During today’s inspection, two (2) clients were at day program.

LPA, accompanied by the Administrator, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was comfortable. The hot water temperature measured at 142 degrees.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked area in the kitchen.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: 10/03/2024
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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per Administrator Saif, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone was not working. Fire extinguisher has been serviced. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff present. There were no clients at the facility during the visit. LPA reviewed multiple staff and client records/files. Files reviewed contained required documents. Confidential records were stored in locked areas. Administrator presented proof of current/active business liability insurance and surety bond.

Deficiencies were observed and cited during today's annual inspection on 809D.

An exit interview was conducted with Administrator Sally Saif to whom copies of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 10/03/2024 03:43 PM - It Cannot Be Edited


Created By: Tiffany Holmes On 10/03/2024 at 11:08 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CRYSTAL CARE FACILITY INC
FACILITY NUMBER: 374604719

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 persons which poses an immediate health, and safety risk to persons in care.
*Hot water was 142 degrees
POC Due Date: 10/04/2024
Plan of Correction
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Licensee immediately turned the dial down on the hot water heater and put up a sign that said Caution- very hot water, be careful. Licensee also called maintanence person to come and correct the issue. Licensee will measure hot water in the am of 10/04/2024 and send LPA a video of water running and thermometer measuring the hot water. POC due to CCL by 10/04/2024
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Denise Powell
LICENSING EVALUATOR NAME:Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/03/2024 03:43 PM - It Cannot Be Edited


Created By: Tiffany Holmes On 10/03/2024 at 11:08 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CRYSTAL CARE FACILITY INC
FACILITY NUMBER: 374604719

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80073(a)
Telephones
(a) All facilities shall have telephone service on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 persons which poses a personal rights risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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Licensee ordered a new battery for the phone during the visit. Licensee will notify LPA when the phone is working properly. POC due date by 10/11/2024
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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4
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:Denise Powell
LICENSING EVALUATOR NAME:Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
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