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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005308
Report Date: 09/28/2021
Date Signed: 09/28/2021 11:51:37 AM

Document Has Been Signed on 09/28/2021 11:51 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CRYSTAL CARE HOMEFACILITY NUMBER:
306005308
ADMINISTRATOR:LAUGUICO, CRISTINAFACILITY TYPE:
740
ADDRESS:9391 TOUCAN AVETELEPHONE:
(714) 553-8674
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 2DATE:
09/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Cristina Lauguico, Licensee/AdministratorTIME COMPLETED:
12:05 PM
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On today’s date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Quiroz was greeted and granted entry into the facility by Licensee/Administrator (L/AD) Cristina Lauguico and explained the nature of the visit.

This facility is licensed to provide services to residents age 60 and over, 6 Non-Ambulatory Residents. L/AD Lauguico has an Administrator Certificate with expiration date of 09/5/2021. L/AD Lauguico indicated she took the Administrator Certificate course on July 21, 2021 and still awaiting for new Administrator certificate. L/AD Lauguico agreed to submit a copy of her new Administrator certificate to CCL upon receiving it.

On or about 10:44am LPA Quiroz along with L/AD Lauguico toured the inside and outside of facility. L/AD Lauguico was observed to be wearing face mask upon arrival to facility. There are two residents in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz observed one of two residents in dinging area working on a jewelry activity exercise. R1 present at the facility during today's visit appeared to be clean and well taken care of. LPA Quiroz observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed to have ample soap/sanitizer and appeared clean. LPA Quiroz inspected residents’ bedrooms and appeared clean and sanitary. All bedrooms observed to have all required components. LPA Quiroz observed a check in station in the main entry of the facility. Facility is taking temperatures daily and documenting results. LPA Quiroz observed the emergency disaster and evacuation plan. Facility has back-up emergency food and water supply as well as PPE supplies. LPA Quiroz toured the outside of the facility and observed seating area with table and chairs for resident’s enjoyment. On 3/12/2021 LPA Micah Martinez read and reviewed the mitigation plan and approved it.

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SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CRYSTAL CARE HOME
FACILITY NUMBER: 306005308
VISIT DATE: 09/28/2021
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During today's inspection visit, LPA Quiroz reviewed two of two resident records. L/AD Lauguico indicated "all residents and staff at facility are fully vaccinated for COVID-19."

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with L/AD Lauguico, and a copy of this report was provided to L/AD Lauguico at exit.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
LIC809 (FAS) - (06/04)
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