198601791-3-26-2025-28-AS-NMAN-DF5VSS-20250326164157

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601791
Report Date: 03/24/2025
Date Signed: 03/26/2025 04:42:09 PM

Document Has Been Signed on 03/26/2025 04:42 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	CRYSTAL MANOR RESIDENTIAL CARE HOME		FACILITY NUMBER:	198601791
ADMINISTRATOR/ DIRECTOR:	CHRISTINA HADDADIN		FACILITY TYPE:	735
ADDRESS:	3406 BALDWIN PARK BOULEVARD		TELEPHONE:	(626) 337-1424
CITY:	BALDWIN PARK	STATE: CA	ZIP CODE:	91706
CAPACITY: 26		CENSUS: 19	DATE:	03/24/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Administrator Christina Haddadin		TIME VISIT/ INSPECTION COMPLETED:	02:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with Administrator Christina Haddadin who assist with the visit. LPA explained the reason for the visit. The facility is licensed to serve (26) twenty-six adults of which (4) four may be non-ambulatory.

The physical plant was inspected along with medications, food supply, and clients and staff records. LPA and Administrator toured the facility and inspected a random selection of client bedrooms, client bathrooms, kitchen, linen room, and laundry room. The patio areas are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the clients located near the entrance of the facility. Passageways and exits are free of obstruction. Extra linens, blankets, towels, and personal hygiene supplies were observed in the linen room and in the garage area. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and working properly. Sharps are locked and are inaccessible to clients. LPA observed laundry detergent, cleaning solutions/disinfectants are stored and locked in the laundry and in the garage area. Multiple fire extinguishers observed in the facility fully charged. Carbon monoxide/smoke detectors observed in the hallway and in the client rooms are operational. The water temperature was tested in all bathrooms and the reading was 110.2 degree F - 112.00 degree F, which is within the required 105F - 120F degrees. Client bedrooms have the required furniture and sufficient closet space. Fire disaster drill was conducted on 01/20/2025.

Continue 809C.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/24/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CRYSTAL MANOR RESIDENTIAL CARE HOME	FACILITY NUMBER: 198601791
	VISIT DATE: 03/24/2025

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The First Aid kit was fully stocked with all required items including a current manual. The medications are centrally stored in the office room and are inaccessible to clients. LPA reviewed clients and staff files. LPA confirmed staff working have fingerprint clearances. LPA observed 1 out of 4 clients file contained a functional capacity assessment that was not signed. LPA reviewed clients medications. Medications are documented properly and given as prescribed.

Observed deficiency is documented on 809D.

Exit interview conducted with Administrator and the copy of the report and appeal rights are provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/24/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/26/2025 04:42 PM - It Cannot Be Edited

Created By: Nune Margaryan On 03/24/2025 at 01:41 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CRYSTAL MANOR RESIDENTIAL CARE HOME	FACILITY NUMBER: 198601791
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80069.2(a)

Functional Capabilities Assessment (a) In order to determine whether the facility's program meets a client's services needs, the licensee of an ARF shall assess the client's need for personal assistance and care by determining his/her functional capabilities. The assessment shall be in writing, shall be used in developing the Needs and Service Plan.... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. On 03/24/25, LPA observed client 1 out of 4 cllents file contained a functional capacity assessment that was not signed & incomplete which may pose a potential risk to persons in care. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/04/2025
	Plan of Correction
1 2 3 4	Licensee / Administrator is to ensure that Title 22 Section 80069.2 regulations are met at all times. Additionally, facility will submit copies of the Functional Capabilities by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:

	Nune Margaryan
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/24/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025

LIC809 (FAS) - (06/04)

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