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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426126
Report Date: 03/20/2025
Date Signed: 03/20/2025 01:39:12 PM

Document Has Been Signed on 03/20/2025 01:39 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CRYSTAL GARDEN RCFEFACILITY NUMBER:
366426126
ADMINISTRATOR/
DIRECTOR:		EBADPOUR, KAMALFACILITY TYPE:
740
ADDRESS:13224 IROQUOISTELEPHONE:
(760) 503-9180
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 10CENSUS: 10DATE:
03/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Breeana RedwineTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Breeana Redwine, Administrator, and discussed the purpose for the visit. The facility is a Residential Care Facility for Elderly (RCFE) with a license capacity of (10), and a current census of (10). LPA conducted a general inspection of facility, which included, but was not limited to, the following:

Operation/Physical Plant: Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility has sufficient indoor and outdoor space for resident activities. The facility is maintained at a comfortable temperature of 74 degrees. Resident bedrooms were furnished with beds, bed linen, nightstands, chairs, and sufficient lighting. Resident bathrooms were maintained clean and equipped with grab rails. The hot water temperature in one of the resident's private bathroom measured at 126 degrees F. Deficiency cited. The facility is equipped with smoke detectors and carbon monoxide alarms, fully charged fire extinguishers, laundry equipment, and telephone service. The facility has posted in a common area Community Care Licensing complaint poster, Ombudsman poster, facility license, evacuation sketch and emergency telephone numbers. Sharps were kept locked and inaccessible to residents in care. The facility staff schedule reflects 24 hours a day, 7 days a week staff coverage.

Food Service: Kitchen and dining areas were maintained cleaned. Non-perishable and perishable food supply was sufficient for number of residents in care. Cups, plates, and utensils were sufficient for number of residents in care. The facility’s refrigerators and freezers were operating properly.

Health Related Services: The facility staff centrally store resident's medications in a locked cabinet. LPA observed in Resident #1 (R1's) medication caddy, pills stored in illegible labeled bottle. LPA was not able to determine the name of resident, medication name, dosage, and expiration dates on the bottle. LPA also observed in R1's medication caddy, (3) unlabeled pills in a plastic container. The Administrator stated the pills were R1's afternoon medications which were transferred into the container. Deficiency cited. ***continued on next page***

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CRYSTAL GARDEN RCFE
FACILITY NUMBER: 366426126
VISIT DATE: 03/20/2025
NARRATIVE
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Record Review: Resident files reviewed had admissions agreements, physician’s reports, appraisals, needs and services plans. Staff files reviewed had First Aid/CPR certifications, criminal record clearances, training, and health screenings. The Administrator’s certification, facility’s insurance and emergency drill training are up to date.

During today's visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where reports (LIC809 & LIC809D) were discussed and copies provided with appeal rights to Administrator Redwine at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 03/20/2025 01:39 PM - It Cannot Be Edited


Created By: Magda Malcore On 03/20/2025 at 12:46 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CRYSTAL GARDEN RCFE
FACILITY NUMBER: 366426126

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPA observations, the licensee did not comply with the section cited above in by hot water temperature measured 125 degrees; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2025
Plan of Correction
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4
During today's visit, Administrator adjusted the water temperature. After adjustment, water temperature was observed to be 110.5 degrees F. No further action required.
Type A
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by R1's had medication with an illegible label stored in their medication caddy; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2025
Plan of Correction
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During today's visit, Administrator disposed of the medication. No further action required.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2025


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 03/20/2025 01:39 PM - It Cannot Be Edited


Created By: Magda Malcore On 03/20/2025 at 12:46 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CRYSTAL GARDEN RCFE
FACILITY NUMBER: 366426126

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on LPA observations, the licensee did not comply with the section cited above by storing Resident #1 (R1's) medication in a plastic cup; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2025
Plan of Correction
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4
During today's visit, Administrator stored resident's the medication in its' proper container. No further action required.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2025


LIC809 (FAS) - (06/04)
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