Crystal Garden Rcfe

FACILITY EVALUATION REPORT

The facility underwent a required annual inspection and was found to have multiple deficiencies, including immediate health risks related to hot water temperature and improper medication storage practices. Specifically, deficiencies were cited for high hot water temperatures, illegible medication labeling, and transferring medications to non-original containers. All cited deficiencies were classified as Type A, indicating an immediate risk to the residents' health or safety.

This report details a complaint investigation conducted on March 4, 2025. The investigation addressed two allegations: residents having catheters when not required, and physician reports being edited by unlicensed personnel. Both allegations were found to be Unfounded or Unsubstantiated based on the evidence gathered.

The facility underwent a required annual inspection and was found to be generally clean and sanitary. However, two deficiencies were cited related to staff training: one concerning hospice care and another concerning dementia care. Both deficiencies require staff training and documentation of completion by April 22, 2024.

The facility underwent a case management visit to approve a capacity change. The inspector noted that the physical plant is ready for the increased capacity, and the licensee was notified of the final approval. No deficiencies were cited during this visit.

This report documents a complaint investigation regarding allegations that the facility failed to provide a refund upon a resident's death. After interviewing staff and the licensee, the investigation concluded that the allegations were unsubstantiated at this time.

The facility underwent a required annual inspection with an emphasis on infection control due to the COVID-19 pandemic. The inspector observed appropriate postings, sufficient hand hygiene and cleaning supplies, and proper use of PPE by staff. No deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

This report details an investigation into multiple allegations of misconduct, including physical abuse, inappropriate staff interactions, and medication mishandling. Based on the evidence gathered, the Licensing Program Analyst determined that all allegations were unsubstantiated.