411408931-3-27-2024-14-AS-MHAN-D3RTJ5-20240327144546

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 411408931
Report Date: 03/27/2024
Date Signed: 03/27/2024 04:37:24 PM

Document Has Been Signed on 03/27/2024 04:37 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	CRYSTAL SPRINGS CARE HOME		FACILITY NUMBER:	411408931
ADMINISTRATOR:	GENNY FLORES		FACILITY TYPE:	740
ADDRESS:	265 ACACIA AVENUE		TELEPHONE:	(650) 871-6218
CITY:	SAN BRUNO	STATE: CA	ZIP CODE:	94066
CAPACITY:	6	CENSUS: 4	DATE:	03/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Caregiver, Consuelo Iman		TIME COMPLETED:	03:00 PM

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	On March 27, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with Caregiver, Consuelo Iman and explained the purpose of the visit. Caregiver called and informed the administrator of the inspection visit. Caregiver provide a toured of the facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA toured the facility inside and outside including all of resident rooms, common areas, and kitchen area. The indoor and outdoor passageways were free of obstruction. Comfortable temperature is maintained and lighting is sufficient for comfort. LPA observed 3 private resident rooms and 1 shared room. Rooms were spacious and included all required furnishings. The bath/shower room for the residents was equipped with paper towels, soap, grab bars, and non-skid mats but it appeared to be dirty with brownish stains on the non-skid mat and shower drain. In addition, the garbage can has rusty stains as well as the metal toilet paper holder that is next to it. LPA observed strong urine smell by the entrance, in the resident's bathroom and in one of the resident's room. LPA also observed fruit files in the kitchen area, the garbage can in the kitchen appeared to have many brownish and whitish particles, the floor in shared resident's room have dried liquid stains, black particles, dust, etc. Hot water temperature in the kitchen, and bathroom was measured at 108- 115 degree F. Extra linen was present. Medications, toxins and sharps were observed to be locked. 2 days for perishables and & 7 days non-perishable were observed to be present. Facility is equipped with smoke detectors and carbon monoxide detectors.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CRYSTAL SPRINGS CARE HOME	FACILITY NUMBER: 411408931
	VISIT DATE: 03/27/2024

NARRATIVE

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A review of (4) resident files was conducted and noted on the LIC 858.
A review of (2) staff files was conducted and noted on the LIC 859.

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with caregiver and administrator who was on the phone.

A copy of this report and the appeal rights were provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/27/2024 04:37 PM - 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
SF COASTAL AC/SC, 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: 03/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(a)

This requirement is not met as evidenced by: 87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times.
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed fruit flies, urine odor, dirty floor in resident's room, brownish and whitish particles on the garbage, brown/rusty stain on the floor surface in the shower room and on the non-skid mat can which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/28/2024
	Plan of Correction
1 2 3 4	The administrator/ licensee will develop a plan to ensure the facility is clean, safe, sanitary and in good repair at all times for residents in care. In the plan, it will include the date that the cleaning process will be completed. The administrator will provide a copy of the signed and dated plan to CCL by 3/28/2024 and upon completion of the cleaning, the administrator will provide photos to proof that the plan of correction has been completed.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 03/27/2024 04:37 PM - 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
SF COASTAL AC/SC, 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: 03/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as facility was not about to provide documentation that drills were conducted accordingly which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/01/2024
	Plan of Correction
1 2 3 4	The administrator will develop a plan to ensure compliance and will provide a copy of the signed and dated plan to CCL by 4/1/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

LIC809 (FAS) - (06/04)

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