397001559-5-10-2024-27-AS-APAA-D55MEH-20240510093244

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397001559
Report Date: 05/09/2024
Date Signed: 05/10/2024 09:33:02 AM

Document Has Been Signed on 05/10/2024 09:33 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	CRYSTAL'S RESIDENTIAL CARE HOME, INC.		FACILITY NUMBER:	397001559
ADMINISTRATOR/ DIRECTOR:	DELOIS BUNCH		FACILITY TYPE:	735
ADDRESS:	1542 EGRET DRIVE		TELEPHONE:	(209) 839-9993
CITY:	TRACY	STATE: CA	ZIP CODE:	95376
CAPACITY: 6		CENSUS: 6	DATE:	05/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Charles Williams		TIME VISIT/ INSPECTION COMPLETED:	11:45 AM

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On 05/09/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA met with Licensee, Charles Williams and explained the purpose of the visit. There was one other staff member present at the facility, Jorge Chanax.

This facility is licensed to serve up to 6 ambulatory residents at this time. This facility is also vendorized by Valley Mountain Regional Center to accept and retain Level 4I residents.
Current census was 6. 6 out of 6 residents were out at their respective day programs.

LPA reviewed 5 staff files and 4 resident files. All resident and staff files were current and up to date. The FDA currently holds an expired certificate #6010183735 however has sent the proper paperwork and payment to the department on 01/03/2024.

A tour of the facility was conducted with Licensee Williams and SM Chanax.
The interior of the physical plant was in good condition and sanitary. Fire extinguishers appeared to have been annually inspected by Armor Fire Extinguisher company and is valid until 08/03/2023. The kitchen area was toured. LPA observed a sufficient seven days of non-perishable foods as well as two days worth of perishable food supplies in the main kitchen. Additional perishable and non-perishable food supplies were identified in the garage. Knives were observed to be locked under the kitchen sink and made inaccessible to the residents at this time.

LPA observed a locked centralized stored medication cabinet located in the hallway. Along with a staff member, the LPAs observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components.

A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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'S RESIDENTIAL CARE HOME, INC.	FACILITY NUMBER: 397001559
	VISIT DATE: 05/09/2024

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A tour of the bedrooms was conducted. Resident furniture was observed to be sufficient to meet their needs at this time. 2 staff bedrooms were also toured.

Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.

A tour of the garage was conducted. Additional non-perishable food supplies were identified. All cleaning supplies were locked and made inaccessible to residents at this time.

The exterior of the physical plant was in good repair with no hazards present. Perimeter fence was observed to be stable and gates were in good repair.

The following forms and documents were requested to be updated and submitted into CCL

-LIC 308

-LIC 400

-LIC 500

-LIC 610

-Liability insurance

No deficiencies were observed or cited during this annual visit. An exit interview was conducted and A copy of this report was provided to the Facility Designated Administrator at the end of the visit.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC809 (FAS) - (06/04)

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