Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197418475
Report Date: 02/08/2018
Date Signed 02/08/2018 02:52:10 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6167 BRISTOL PARKWAY #400
CULVER CITY, CA 90230
FACILITY NAME:CRYSTAL STAIRS INC.- SULLIVANFACILITY NUMBER:
197418475
ADMINISTRATOR:JONES-LOWE, CONNIEFACILITY TYPE:
850
ADDRESS:725 W. RAYMOND STREETTELEPHONE:
(310) 933-0760
CITY:COMPTONSTATE: CAZIP CODE:
90220
CAPACITY:120CENSUS: 104DATE:
02/08/2018
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Maria Navarro, Site SupervisorTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA), Tiffanie Tran conducted a case management inspection to deliver an immediate exclusion Removal for Eric Hill. LPA met with Maria Navarro, Site Supervisor.

Site Supervisor had contacted human resources to get confirmation the above individual and was verified that this individual had never hired or work for the agency. Based on evidence obtained during today’s visit, LPA has verified the individual is not present at the facility. LPA has advised the licensee to disassociate the individual from their roster and submit an updated LIC 500.

A copy of a confirmation of removal was completed by site supervisor, Maria Navarro and obtained by LPA for the record.

An exit interview conducted. This copy was provided to the noted person.
SUPERVISOR'S NAME: Sharon GreeneTELEPHONE: (310) 337-4313
LICENSING EVALUATOR NAME: Tiffanie TranTELEPHONE: 310-337-4335
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2018
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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