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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 550317017
Report Date: 01/31/2024
Date Signed: 04/09/2024 05:15:24 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/09/2024 05:15 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: DATE:
01/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Andrea HallTIME COMPLETED:
04:00 PM
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On 1/31/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual inspection. LPA Jensen met with Administrative Assistant Andrea Hall and explained the purpose of today's visit. The Administrator, Mona Gaskill, holds current certificate #6011648735 good through 2/25/25. LPA Jensen met briefly with Administrator Mona Gaskill and kept in contact with her by phone throughout the inspection. The current census is 6. Clients were on an outing at the time of this inspection.

LPA Jensen toured the facility grounds. There are shaded areas and outdoor furniture available for client enjoyment. There are no bodies of water on the property. The physical plant has two stories with bedrooms and staff quarters on the first floor and a common living area, kitchen and additional bedrooms on the second floor. All windows were recently replaced and window screens are in good repair. The living room and kitchen were recently remodeled and second floor bathroom is also scheduled for a remodel in or around the next 6 months. The facility was observed to be sanitary and free of odor. There was adequate lighting and furniture throughout. LPA Jensen toured the kitchen and observed in excess of a 2 day supply of perishable food and a 7 day supply of non-perishable food. There was fresh vegetables, produce and snacks available for clients. Knives were locked and inaccessible to residents in care. Toxins and medications were locked and inaccessible. The menu was posted in a location easily viewable by residents. The facility also maintains an emergency food and water supply. LPA Jensen inspected the resident bedrooms and observed 2 bedrooms that were without chairs. Technical assistance was provided. A bedroom on the first floor has a door leading to staff quarters. Technical assistance was provided. The facility maintains an adequate supply of linens and towels.

LPA Jensen reviewed 6 of 6 client files and found them to be complete and in compliance. LPA Jensen reviewed 6 of 6 staff files and found them to be in compliance. LPA Jensen interviewed 1 staff member that was able to respond competently to all questions.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: CRYSTAL FALLS FAMILY CARE HOME
FACILITY NUMBER: 550317017
VISIT DATE: 01/31/2024
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The fire extinguisher was last serviced in August of 2023 and is in compliance. LPA Jensen tested the smoke detector and carbon monoxide detector and found them to be in good working order. The facility has a generator on site in the event of a power outage. There is emergency lighting available. The facility conducts and logs monthly fire drills. The facility has a current and compliant infection control plan. There is a first aid kit on site that is complete.

There are a variety of activities available for client enjoyment tailored to individual client interests. The facility also has outings multiple times a week and does an annual destination vacation.

The inspection tool was used during the course of this annual visit. The facility was observed to be in substantial compliance and no deficiencies are being cited. An exit interview was conducted and a copy of this report was handed to Andrea Hall.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
LIC809 (FAS) - (06/04)
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