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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 550317017
Report Date: 03/20/2025
Date Signed: 03/20/2025 10:07:55 PM

Document Has Been Signed on 03/20/2025 10:07 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/
DIRECTOR:
GASKILL,MONAFACILITY TYPE:
735
ADDRESS:17192 NILE RIVER DRIVETELEPHONE:
(209) 586-1667
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY: 6CENSUS: 5DATE:
03/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Care staff Jed HanesTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Jason Lund arrived at facility unannounced to conduct a annual/required inspection. LPA Lund met with Care staff Jed Hanes. LPA Lund spoke with administrator, Mona Gaskill, who could not make the visit and gave permission for Care staff Jed Hanes to sign paperwork. Census 5.

LPA Lund & Care staff Jed Hanes toured/inspected the facility grounds. There are shaded areas and outdoor furniture available for client enjoyment. 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. The living room and kitchen were was observed to be sanitary. The facility was observed to be sanitary and free of odor. There was adequate lighting and furniture throughout. LPA Lund inspected the kitchen and observed in excess of a 2- day supply of perishable food and a 7- day supply of non-perishable food. 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 Lund reviewed 3 of 6 client files and found them to be complete and in compliance. LPA Lund reviewed 2 of 6 staff files and found them to be in compliance. Fire extinguisher was last serviced in August of 2024 and is in compliance. 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. First aid kit on site that is complete.

No deficiencies are being cited. An exit interview held copy of report left.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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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