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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005308
Report Date: 09/29/2025
Date Signed: 09/29/2025 05:04:45 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/29/2025 05:04 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CRYSTAL CARE HOMEFACILITY NUMBER:
306005308
ADMINISTRATOR/
DIRECTOR:		LAUGUICO, CRISTINAFACILITY TYPE:
740
ADDRESS:9391 TOUCAN AVETELEPHONE:
(714) 553-8674
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 5DATE:
09/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Crystal Lauguico, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On September 29, 2025, at 2:00pm, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Bentley was greeted and granted entry by Administrator (AD) Cristina Lauguico, after announcing the purpose of the visit.

The facility is licensed to operate for six (6) non-ambulatory elderly residents. The building is a single story structure located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, three (3) staff bedrooms, two (3) bathrooms, living area, dining area, kitchen, an outdoor covered seating areas, and an attached two car garage.

LPA Bentley toured inside and outside of the physical plant with AD Lauguico. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked and available at the time of visit. Bathrooms were found to be clean and operational. The water temperatures in bathrooms measured at 108.6 degrees F to 109.2 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility.

LPA Bentley observed the facility to be appropriately furnished at the time of visit, however, there was clutter in the kitchen and garage. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available. An emergency safety drill was last conducted on September 19, 2025, and are conducted quarterly. First aid kit is maintained and contains all the necessary elements.

CONTINUE TO LIC809-C.....

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2025
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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Document Has Been Signed on 09/29/2025 05:04 PM - It Cannot Be Edited


Created By: Eboni Bentley On 09/29/2025 at 04:38 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CRYSTAL CARE HOME
FACILITY NUMBER: 306005308

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/29/2025
Section Cited
CCR
87309(a)

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(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
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During the inspection, the licensee secured these items and LPA confirmed. Licensee stated they will train staff on securing
dangerous items and submit proof to LPA by 9/30/2025.
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Based on observation, the licensee did not ensure medication was inaccessible in R1 & R2 bedroom and staff's medications in an un-locked kitchen drawer, which poses an immediate safety risk to persons in care. LPA also observed sharps in R1's desk drawer.
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Type B
09/29/2025
Section Cited
CCR87303(a)

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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
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Licensee stated they will deep clean all common areas, including kitchen, garage and bathroom throughout the facility. Licensee will also clean residents bedrooms and submit proof to LPA by 9/30/2025.
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Based on observation, the licensee did not ensure the facility was clean and sanitary, which poses a potential risk to residents in care. LPA observed clutter in the kitchen on two counters, in cabinets and in garage. LPA also observer four dogs in the facility and pet dander in the air, throughout the facility.
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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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2025


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CRYSTAL CARE HOME
FACILITY NUMBER: 306005308
VISIT DATE: 09/29/2025
NARRATIVE
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During the visit, all mandated inspection control posters were posted. The smoke detectors and carbon monoxide detectors were operable. A working telephone (714-274-9594) remains available, and the facility has a device that can be used for video teleconference purposes. Emergency food, emergency water, and emergency supplies were stored in the garage. The facility has two (2) fire extinguishers that were charged, mounted, and serviced on July 9, 2025. Liability Insurance is effective September 25, 2025, and expires on September 25, 2026.

LPA Bentley conducted an audit of five (5) resident files (R1-R5), three (3) staff files (S1-S3), and medication and medication administration review were all in order and complete. LPA Bentley conducted five (5) resident interviews and one (1) staff interviews.

Based on observations, deficiencies were cited during the visit, per Title 22, Division 6 of the California Code of regulations. An exit interview was conducted, and a copy of this report, LIC809-D, and Appeal Rights was provided to Administrator Cristina Lauguico.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2025
LIC809 (FAS) - (06/04)
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