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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701576
Report Date: 09/19/2025
Date Signed: 09/19/2025 01:37:57 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/08/2025 and conducted by Evaluator Liza King
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250808081449
FACILITY NAME:CRYSTAL CREEK SENIOR LIVINGFACILITY NUMBER:
392701576
ADMINISTRATOR:PUNNI,MANISHAFACILITY TYPE:
740
ADDRESS:2435 WAGNER HEIGHTS ROADTELEPHONE:
(209) 477-5353
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:80CENSUS: 65DATE:
09/19/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Angela Riungu TIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility does not have an administrator
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kesha Lewis and Licensing Program Manager (LPM) Liza King arrived unannounced to conduct a complaint investigation and follow up incidents that the department has become aware of which need additional follow up. LPM and LPA met with Angela Riungu and explained the purpose of the visit.
According to interview and records review, previous Admin last day 07/31/25, current Admin start date date 08/11/25 however documents were not receieved in the RO by the licensee to appoint the individual. Admin Cert 7028459740 exp 07/25/26 and meets all educational experience. On todays date documents were requested to incl.
o A letter from the licensee and/or Board appointing the individual as the
Administrator
o LIC308
o Copy of current Admin Cert
o Any documentation that meets the education and/or experience requirements, if applicable
o LIC 200 signed by the licensee or designee
o LIC 500 to indicate the days/hours the administrator is in the facility
o LIC 501 so that we can determine if the admin meets the education/ experience requirement.
Cont.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Krystall Moore
LICENSING EVALUATOR NAME: Liza King
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20250808081449
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CRYSTAL CREEK SENIOR LIVING
FACILITY NUMBER: 392701576
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/22/2025
Section Cited
CCR
87205(a)
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87205 Accountability of Licensee Governing Body
(a) The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves. This regulation was not met as evidenced by:
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Documents will be submitted via email by POC date.
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The licensee failied to provide the requested documentation to the department to verify qualifications and assign the prospective Administrator. Date of hire: 08/11/25
This poses a potential risk to cllients in care.
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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.
SUPERVISORS NAME: Krystall Moore
LICENSING EVALUATOR NAME: Liza King
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20250808081449
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: CRYSTAL CREEK SENIOR LIVING
FACILITY NUMBER: 392701576
VISIT DATE: 09/19/2025
NARRATIVE
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LPM verified fingerprint clearance and association which show effective 08/16/2025.

Based on documentation and interviews it was determined the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations is being cited on the attached LIC 9099D. Appeal Rights have been provided and an exit interview with Angela was conducted to discuss these finding.
SUPERVISORS NAME: Krystall Moore
LICENSING EVALUATOR NAME: Liza King
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3