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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 411408931
Report Date: 03/17/2025
Date Signed: 03/17/2025 11:47:54 AM

Document Has Been Signed on 03/17/2025 11:47 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
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:
03/17/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Caregiver, Consuelo ImanTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On March 17, 2025, Licensing Program Analyst (LPA) Murial Han conducted a plan of correction visit for the annual inspection that was conducted on March 4, 2025. LPA met with caregiver, Consuelo Iman and explained the purpose of the visit. Caregiver, called and informed administrator, Genny Flores of LPA's visit.

During today's visit, LPA toured the common areas, bath/shower room, dining room, living room, resident room, etc., reviewed the deficiencies with administrator over the phone and reviewed documents.

The following deficiencies , which were cited on 3/4/2025 are corrected:
- 87303(a) Maintenance and Operation
- 87303(a)(1) Maintenance and Operation
- 87303(c) Maintenance and Operation
- 87309(a) Storage Space and Access
- 1569.695(c) Emergency Drills
- 87457(c) Pre-Admission Appraisal
- 87463(a) Reappraisal

In regards to Postural Support 87608(a)(3), the administrator has requested for an extension and it was granted.

A copy of the Cleared Plan of Correction Letters provided the caregiver.

No deficiency cited today.

This report is reviewed and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2025
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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