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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005379
Report Date: 02/22/2022
Date Signed: 02/22/2022 01:31:36 PM

Document Has Been Signed on 02/22/2022 01:31 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CRYSTAL COVE CARE #1FACILITY NUMBER:
306005379
ADMINISTRATOR:CALISHER, ERICFACILITY TYPE:
740
ADDRESS:18600 LOS LEONES STTELEPHONE:
(714) 593-2687
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
02/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Melchor RodriguezTIME COMPLETED:
01:46 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required inspection visit. LPA was greeted and granted entry into the facility by caregiver. LPA met with caregiver and explained the nature of the visit.

LPA accompanied by caregiver toured the inside and outside of the facility. The facility currently has 6 residents in care. LPA observed residents in dinning room having lunch. All residents appeared happy and well taken care of. Facility appears clean and sanitary. Facility staff screens all visitors to the facility and LPA observed the screening station in the entrance of the facility. Facility keeps documentation in regard to covid for all the staff and residents. LPA observed that the facility has covid precautionary postings throughout the facility as well as all required department postings. Facility has an active covid-19 prevention plan in place for the safety of resident in care. LPA observed facility to have emergency food supply, PPE, incontinence, and cleaning supplies. Facility has sanitation precaution in place throughout the facility and all common spaces. LPA toured the outside and observed a shaded outside space for residents, area is used for outdoor visitation as well. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation as needed. Facility bedrooms are currently single occupancy. LPA was informed that staff have their booster shot and most of resident have their booster shots. The facility has completed the LIC808 Mitigation Plan, LPA reviewed and approved the plan on today’s visit.

Based on the observations 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 facility representative and a copy of this report was provided and left at facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2022
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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