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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 411408931
Report Date: 03/15/2022
Date Signed: 03/15/2022 09:57:32 AM


Document Has Been Signed on 03/15/2022 09:57 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:CRYSTAL SPRINGS CARE HOMEFACILITY NUMBER:
411408931
ADMINISTRATOR:CAMACLANG, ALBERTINAFACILITY TYPE:
740
ADDRESS:265 ACACIA AVENUETELEPHONE:
(650) 871-6218
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: 5DATE:
03/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Caregiver, Consuelo ImanTIME COMPLETED:
10:15 AM
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On March 15, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival, LPA observed signage on the front door. LPA met with Caregiver, Consuelo Iman and explained the purpose of the visit. LPA was not screened at the entry point. LPA Charitra observed screening log documentation for visitors, however the Caregiver was unable to provide screening log documentation for residents and staff.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are not present: entry procedures, daily monitoring for residents and staff, and 30-day PPE supply. Bathrooms are equipped liquid soap and paper towels. LPA advised caregiver to not keep any bar soaps in the bathroom, cover all trash cans with lids, and make sure all bathrooms have hand-washing signage.

Signs are present regarding masking and distancing but LPA discussed the need to add more reminder signs for residents regarding cough etiquette and COVID symptoms. LPA observed 4 private rooms and 1 shared room with beds 6ft apart. LPA toured the kitchen and advised caregiver not have hand-towels present.

Medications, toxins and sharps are stored appropriately and inaccessible to residents, and a comfortable temperature is maintained, lighting is sufficient for comfort. First aid kit was observed to be completed. Extra linen was observed to be present.

LPA requests the following to be sent by 3/22/22:
-LIC308 Designation of Administrative Responsibility
-LIC500 Personnel Report
-Administrator Certificate
-LIC610E Emergency Disaster Plan

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with the caregiver; a copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2022
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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Document Has Been Signed on 03/15/2022 09:57 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: CRYSTAL SPRINGS CARE HOME
FACILITY NUMBER: 411408931

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/22/2022
Section Cited

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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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The facility failed to provide documentation for the daily residents and staff members screening log; the facility failed to maintain a 30-day PPE supply; the facility failed to cover all trash cans with lids.
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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.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2022
LIC809 (FAS) - (06/04)
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