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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604719
Report Date: 01/22/2025
Date Signed: 01/22/2025 05:25:41 PM

Document Has Been Signed on 01/22/2025 05:25 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: 3DATE:
01/22/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:11 AM
MET WITH:Sally Saif, Administrator TIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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Licensing Program Analysts (LPAs) Tiffany Holmes and Arian Golbakhsh 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: 01/08/2025. The facility properly reported C1 going AWOL. C1 returned on 01/10/2025.

C1 was AWOL'd again on 01/15/2025 and returned on 01/18/2025. When the client returned they had discharge paperwork and showed a positive urinalysis. Interview with Administrator stated that they have reached out to the San Diego Regional Center worker regarding a drug program for C1.

Interviews and a record review revealed, C1 LIC 602 dated 10/07/2024 states they can 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 is on a family visit.

An exit interview was conducted with the Administrator. A copy of this report along with Licensee/Appeal Rights (LIC9058 03/22) was provided to Saif at the conclusion of the visit.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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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