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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604719
Report Date: 09/05/2025
Date Signed: 09/10/2025 01:17:56 PM

Document Has Been Signed on 09/10/2025 01:17 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:
09/05/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Sally Saif, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:17 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: 09/02/2025. The facility properly reported C1 going AWOL. The facility's Missing Persons/Absentee Notification Plan was reviewed on today's date with the Licensee.

On 08/27/2025 C1 went AWOL. Interviews revealed that around 8pm, C1 stated that they didn't feel well and stated they wanted to "Get fresh air". Interviews revealed that staff stayed with C1 outside when C1 stated that they are getting agitated and doesn't feel well. Staff called the administrator and described the situation and stated that they went out to check on C1 again outside, and C1 was no where to be found, Staff looked everywhere and around the facility as well as the back and front yard and there were no signs of C1. Interviews revealed that the staff waited 10 minutes and checked again and then called 911 to report C1 missing. According to C1s physician report they are able to leave the facility unassisted and they have community access plan. Interviews revealed that C1 was found in their room on 8/28/25 at 5am. Interviews revealed while they were assessing the client they reported that they were at Paradise Valley Hospital and that they called the ambulance for abdominal pain. No other information or papers were provided to staff from C1.

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. 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.
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Tiffany Holmes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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