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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604719
Report Date: 11/07/2024
Date Signed: 11/07/2024 02:34:46 PM

Document Has Been Signed on 11/07/2024 02:34 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: 4DATE:
11/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:34 PM
MET WITH:Sally Saif, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:45 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: November 04 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 went outside of the the facility around 7pm to get some fresh air. C1 did not return to the facility. Around 2am the hospital called the administrator to let them know C1 called 911 and was on a hold due to suicidal ideations. C1 was released from the psych unit and returned to the facility on 11/05/2024.

Interviews and a record review revealed, C1 LIC 602 dated 10/07`2024 states they can now 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. LPA conducted interviews on this date. LPA received copies of pertinent information regarding C1.

No deficiencies were cited or observed on this date. According to interviews C1 will have a family visit for the weekend extended one day due to the holiday and the licensee will have C1 assessed medically for the suicidal ideations.

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: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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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