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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 550317017
Report Date: 02/27/2023
Date Signed: 02/27/2023 04:40:35 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/27/2023 04:40 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CRYSTAL FALLS FAMILY CARE HOMEFACILITY NUMBER:
550317017
ADMINISTRATOR:GASKILL,MONAFACILITY TYPE:
735
ADDRESS:17192 NILE RIVER DRIVETELEPHONE:
(209) 586-1667
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY: 6CENSUS: 6DATE:
02/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:32 PM
MET WITH:Andera HallTIME COMPLETED:
01:33 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. Upon arrival LPA was confronted with heavy snow and had to leave the facility, because the snow was impending driving and made for unsafe travel. LPA drove to a safe location and called Licensee and made arrangements for a virtual visit. LPA will return at a later time to conduct an in-person inspection.
LPA virtually via facetime inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards (five inches of snow in 30min). LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies.

Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications. Fire drill was completed on 2/17/2023.

All staff are Fingerprint cleared and associated to the facility. First aid kit was checked and is complete.

No deficiencies were cited pursuant to Title 22 rules and regulations, Health and Safety Codes.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2023
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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