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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426126
Report Date: 03/04/2025
Date Signed: 03/04/2025 11:25:39 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/07/2021 and conducted by Evaluator Becky Mann
COMPLAINT CONTROL NUMBER: 18-AS-20210407133529
FACILITY NAME:CRYSTAL GARDEN RCFEFACILITY NUMBER:
366426126
ADMINISTRATOR:EBADPOUR, KAMALFACILITY TYPE:
740
ADDRESS:13224 IROQUOISTELEPHONE:
(760) 503-9180
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY:10CENSUS: 10DATE:
03/04/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Breeana Redwine, AdministratorTIME COMPLETED:
11:35 AM
ALLEGATION(S):
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9
Residents are equipped with catheters when not required to be
Residents Physician Report's edited by unlicensed physician
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Becky Mann conducted an unannounced visit to the facility to initiate a complaint investigation. LPA met with Breeana Redwine, Administrator and discussed the purpose of the visit. The investigation consisted of LPA pertinent record reviews and interviews with staff and residents.

The allegation that Residents are equipped with catheters when not required to be. Based on interviews with administrator, staff, and outside hospice agency, all have denied this allegation.
The allegation that Residents Physician Report’s edited by unlicensed physician. Based on LPA observations, there were no documentation and/or evidence to corroborate the allegation.

Based on evidence obtained during this investigation, the allegations are Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
An exit interview was conducted where this report was discussed and a copy of this report was provided to the Breeana Redwine, Administrator at the conclusion of the visit.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/07/2021 and conducted by Evaluator Becky Mann
COMPLAINT CONTROL NUMBER: 18-AS-20210407133529

FACILITY NAME:CRYSTAL GARDEN RCFEFACILITY NUMBER:
366426126
ADMINISTRATOR:EBADPOUR, KAMALFACILITY TYPE:
740
ADDRESS:13224 IROQUOISTELEPHONE:
(760) 503-9180
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY:10CENSUS: 10DATE:
03/04/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Breeana Redwine, AdministratorTIME COMPLETED:
11:35 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Residents face punishment by staff when not participating in activities
Staff do not provide adequate care for the residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Becky Mann conducted an unannounced visit to the facility to initiate a complaint investigation. LPA met with Breeana Redwine, Administrator and discussed the purpose of the visit. The investigation consisted of LPA pertinent record reviews and interviews with staff and residents.

The allegation that Residents face punishment by staff when not participating in activities. All staff interviewed denied that they punish residents when residents do not participate in activities. Residents interviewed stated that they do not face punishment by staff when they do not participate in activities.

The allegation that Staff do not provide adequate care for the residents. All staff interviewed denied the allegation and they do provide adequate care for the residents. Residents interviewed stated that staff does provide adequate care for the residents.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20210407133529
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CRYSTAL GARDEN RCFE
FACILITY NUMBER: 366426126
VISIT DATE: 03/04/2025
NARRATIVE
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Based on evidence obtained during this investigation, the allegations above are Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where this report was discussed and a copy of this report was provided to the Breeana Redwine, Administrator at the conclusion of the visit.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3