<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701576
Report Date: 04/22/2026
Date Signed: 04/22/2026 12:18:26 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
02/06/2026 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20260206104333
FACILITY NAME:CRYSTAL CREEK SENIOR LIVINGFACILITY NUMBER:
392701576
ADMINISTRATOR:ANGELA RINGUFACILITY TYPE:
740
ADDRESS:2435 WAGNER HEIGHTS ROADTELEPHONE:
(209) 477-5353
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:80CENSUS: 72DATE:
04/22/2026
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jennifer AlmendarezTIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure that insulin administration to residents was performed by an appropriately skilled professional
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 4-22-2026 at 10:15am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegation noted above. LPA met with Health and Wellness Director Jennifer Almendarez and explained the purpose of the visit. During this investigation, LPA conducted interviews with five staff members and reviewed facility file documentation including medication logs for January and February of 2026, and facility’s medication policy.
Allegation: Staff did not ensure that insulin administration to residents was performed by an appropriately skilled professional. LPA conducted interviews and record reviews as noted above. Based on these interviews and record reviews, it was revealed that at the time of review, a total of 15 residents received insulin via flex pen. Interviews also revealed that five of these residents were unable to determine what the dosage should be and required assistance as a result. A review of facility’s medication policy states in part: "Properly trained med techs may physically assist a resident with setting the dial of an insulin multi-dose pen according to physician's orders. If resident is unable to determine what the dosage should be, med techs cannot assist with setting the dial..." {Cont. on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026
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-20260206104333
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: 04/22/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Interviews conducted revealed corroborated statements that med techs assisted these five residents with their insulin flex pens by turning the dial for appropriate dosage on various dates and times between January and February of 2026. A review of medication log sheets indicated these residents were assisted with their insulin flex pens with confirmation via med tech initials present on these log sheets.

As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Citation is issued under Title 22, Division 6, and noted on LIC 9099D. An exit interview was conducted with Health and Wellness Director and a copy of this report was provided. Appeal rights and LIC 811 provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20260206104333
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: 04/22/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/23/2026
Section Cited
CCR
87465(a)(4)
1
2
3
4
5
6
7
87465 Incidental medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility… (4) The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee will ensure completed staff training on proper assistance with medications with topics to include but not be limited to: Diabetes, injections, use of insulin flex pen, and general medication assistance with self-administration of medication in addition to facility’s written medication policy. Training date to be submitted to LPA by POC due date. Proof of completed training to be submitted to LPA by 5/6/2026
8
9
10
11
12
13
14
 Based on interviews and record reviews, Licensee did not ensure that an appropriately skilled professional assisted residents as needed with self-administering insulin flex pen injections. This posed an immediate health and safety risk to residents in care.

8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3