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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002761
Report Date: 02/15/2024
Date Signed: 02/16/2024 12:30:11 PM

Document Has Been Signed on 02/16/2024 12:30 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CRYSTAL'S RESIDENTIAL CARE HOME #2FACILITY NUMBER:
397002761
ADMINISTRATOR:CHARLES WILLIAMSFACILITY TYPE:
735
ADDRESS:1259 DOVE DRIVETELEPHONE:
(209) 832-2066
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY: 6CENSUS: 5DATE:
02/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Charles Williams TIME COMPLETED:
03:30 PM
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On 02/15/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a 1-year annual visit. LPA Pascua was greeted by staff member, Olive Ngoula and was asked to call the Facility Designated Administrator, Charles Williams to let him know that CCL was present at this time. Shortly after, FDA Williams arrived and met with LPA Pascua. This facility is licensed for 6 residents and is vendorized by Valley Mountain Regional Center to served 4I residents at this time.
Current census was 5. All 5 residents are at the respective day program.
LPA reviewed 3 resident files and 2 staff files. All files are complete and up to date.
The administrator holds a current administrator's certificate #60132775735 and expires on 03/18/2024.
A tour of the facility was conducted.

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 08/04/2024. 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 in a kitchen cabinet 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.

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

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2024
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 #2
FACILITY NUMBER: 397002761
VISIT DATE: 02/15/2024
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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: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC809 (FAS) - (06/04)
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