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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 550317017
Report Date: 02/07/2022
Date Signed: 02/11/2022 08:58:41 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/11/2022 08:58 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
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:
02/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Facility staff, Andrea Hall TIME COMPLETED:
05:45 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Andrea Hall Continual Administrator's Certification expires 02/25/2023. There are currently 6 residents who reside at this home. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 109 degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. LPA observed all facility staff present has background clearance. LPA reviewed facility staff files and they did not have vaccine records or exemptions.

LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

The following deficiency was cited per Title 22 Division 6 Chapter 6 of the California Code of Regulations. An exit interview was conducted with Facility staff Andrea Hall and a copy of this report along with appeal rights was provided.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2022
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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Document Has Been Signed on 02/11/2022 08:58 AM - It Cannot Be Edited


Created By: Sarah Hurt On 02/07/2022 at 04:43 PM
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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CRYSTAL FALLS FAMILY CARE HOME
FACILITY NUMBER: 550317017

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/16/2022
Section Cited
CCR
85064(m)

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85064 (m)Adminstrator Qualifications and Duties . In those cases where the individual is both the licensee and the administrator of an adult residential facility, the individual shall comply with all of the licensee and certified administrator requirements. This requirement has not been met as evidenced by:
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Licensee will submit vaccine records or exemptions to LPA by 02/16/2022 POC date.
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Based on records reviewed the licensee did not ensure facility staff has vaccine cards or exemptions in files which poses a potentiol risk to residents in care.
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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:Stephenie Doub
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2022


LIC809 (FAS) - (06/04)
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