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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 03:40:55 PM

Document Has Been Signed on 10/03/2024 03:40 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:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:Sally Saif, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Case Management visit. LPA identified themselves to Sally Saif, Administrator we discussed the purpose of the visit.

Today's visit is in response to the AWOL of Client 1 (C1) date of incident: September 29 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 AWOL, C1 left the facility at roughly 7pm and walked down to the 711 and called 911. C1 was found a short time later at the emergency room around 9pm, when the administrator called around and knew that is where C1 was going to end up at. C1 then proceeded to AWOL from the ER against medical advice. At that time C1 had not returned to the facility as of yet. The next day on September 30, 2024 law enforcement did find C1 sleeping on a bench at a park around 11 pm. Law enforcement took C1 to a surrounding neighborhood hospital emergency room, where C1 was there until October 1, 2024. According to the administrator C does not have any injuries.
Interviews and a record review revealed, C1 LIC 602 dated July 3,2024 states they cannot leave the facility unassisted, and C1 does have a history of AWOLing at this facility and prior facilities and it is documented on their Individual Program Plan (IPP). The facility did notify appropriate parties and took appropriate measures by notifying law enforcement upon C1 AWOL. Interviews revealed they are working with the behavior therapist and SDRC to gain a community access plan for the client. The administrator has made a doctors appointment for the client to be reassessed for possible community access. The appointment is scheduled for October 7, 2024. LPA conducted interviews on this date. 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: 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)
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