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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 411408931
Report Date: 03/04/2025
Date Signed: 03/04/2025 06:41:02 PM

Document Has Been Signed on 03/04/2025 06:41 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:CRYSTAL SPRINGS CARE HOMEFACILITY NUMBER:
411408931
ADMINISTRATOR/
DIRECTOR:		GENNY FLORESFACILITY TYPE:
740
ADDRESS:265 ACACIA AVENUETELEPHONE:
(650) 871-6218
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 6CENSUS: 3DATE:
03/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Caregiver, Consuelo ImanTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
NARRATIVE
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On March 4, 2025, 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. The administrator arrived during the inspection.

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. The shower floor observed to be dirty, and soiled clothes were place on the floor to prevent water from overflowing to the toilet side.

During the tour of the facility, LPA observed fruit files thought-out the facility, a black plastic garbage can in the kitchen appeared to be greasy, have many brownish and whitish particles, the kitchen floor has hair, dirt, and used Q-tip, the kitchen sink has a plastic bag tide around the faucet with garbage inside, the closet door in R1's room is broken, spider webs on the window frames, light fixtures, etc., a white bucket by the refrigerator in the kitchen has black dust inside and an unidentified electrical device, toaster over in the kitchen was greasy and filled with dried brown and black particles, the floor board trims through-out facility appeared to black, brown with chipped paint.


SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
Document Has Been Signed on 03/04/2025 06:41 PM - It Cannot Be Edited


Created By: Murial Han On 03/04/2025 at 11:38 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the LPA observed the entire facility to be not cleaned and safe (see LIC809 for details) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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The administrator will develop a plan in writing to ensure the facility is clean, safe, sanitary and in good repair at all times. The plan should indicate the date that the facility will complete a deep cleaning and the date shall be on later than 3/14/2025. The plan shall also indicate what is the procedure to ensure compliance and who is going to monitor it. The plan shall also include staff in-service. The administrator will provide a copy of the plan to CCL 3/5/2025.
Type A
Section Cited
CCR
87303(a)(1)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above The shower floor observed to be dirty, and soiled clothes were place on the floor to prevent water from overflowing to the toilet side which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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The administrator will develop a plan to ensure compliance and the plan shall include staff in-service and the date of compliance shall be no longer than 3/14/2025. The administrator will provide a copy of the plan to CCL by 3/5/2025.
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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 03/04/2025 06:41 PM - It Cannot Be Edited


Created By: Murial Han On 03/04/2025 at 11:38 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed spider webs on the window screens through-out the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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The administrator will develop a plan in writing to ensure the window screens are cleaned. The plan should indicate the date that the facility will complete the cleaning process and the date shall be on later than 3/14/2025. The plan shall also indicate what is the procedure to ensure compliance and who is going to monitor it. The plan shall also include staff in-service. The administrator will provide a copy of the plan to CCL 3/5/2025.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed sharps are not locked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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The administrator will develop a plan in writing to ensure compliance and will submit a copy of the plan to CCL by 3/5/2025.
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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 03/04/2025 06:41 PM - It Cannot Be Edited


Created By: Murial Han On 03/04/2025 at 11:38 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the administrator was not able to provide proof that drills were conducted accordingly which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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The administrator will develop a plan to ensure compliance and will conduct a drill by 3/14/2025. The administrator will provide a copy of staff training record and a copy of the plan of correction to CCL by 3/5/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 03/04/2025 06:41 PM - It Cannot Be Edited


Created By: Murial Han On 03/04/2025 at 11:38 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as R2 did not have a pre-admission appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2025
Plan of Correction
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The administrator will develop a plan to ensure a pre-admission appraisal is complete for the residents. The administrator will provide a copy of the plan of correction and R2's appraisal to CCL by 3/12/2025.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above LPA R1 did not have an updated reappraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2025
Plan of Correction
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The administrator will develop a plan to ensure reappraisals are completed for all the residents and will provide a copy of R1's reappraisal and the plan of correction to CCL by 3/12/2025
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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 03/04/2025 06:41 PM - It Cannot Be Edited


Created By: Murial Han On 03/04/2025 at 11:38 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above LPA observed R3 has bedrails without an order which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2025
Plan of Correction
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The administrator will develop a plan to ensure residents who have postural support have an written order. The administrator will provide a copy of the order for R3 and a copy of the plan of correction to CCL by 3/12/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: CRYSTAL SPRINGS CARE HOME
FACILITY NUMBER: 411408931
VISIT DATE: 03/04/2025
NARRATIVE
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LPA observed sharps were opened and accessible to residents in care. In addition, the sharps drawer appeared to be dirty and the sharps appeared to be old and rusty.

Hot water temperature in the kitchen, and bathroom was measured at 105- 109 degree F. Extra linen was present. Medications were locked and inaccessible to residents. 2 days for perishables and & 7 days non-perishable were observed to be present.

A review of (3) resident files was conducted and noted on the LIC 858.
A review of (2) staff files was conducted and noted on the LIC 859.

Civil penalty of $500 is being assessed for 2 repeat violations that were observed during the annual inspection in 2024.

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 additional civil penalties.

LPA provided an exit tour to the administrator and identified the deficient areas that were cited today.

The administrator will provide a copy of the administrator certification and the liability insurance by 3/6/2025.

This report is reviewed and discussed with administrator.

A copy of this report and the appeal rights were provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC809 (FAS) - (06/04)
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