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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201180
Report Date: 03/23/2023
Date Signed: 03/23/2023 12:38:08 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/20/2023 and conducted by Evaluator Liridon Fici
COMPLAINT CONTROL NUMBER: 15-AS-20230320102453
FACILITY NAME:KRISTA & KRIS CORPORATIONFACILITY NUMBER:
019201180
ADMINISTRATOR:ALFONSO, AMELIAFACILITY TYPE:
735
ADDRESS:5541 ROOSEVELT PLACETELEPHONE:
(650) 255-9603
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:6CENSUS: 5DATE:
03/23/2023
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:ALFONSO, AMELIA, AdministratorTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Facility not providing adequate staffing for clients in care.
INVESTIGATION FINDINGS:
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On 3/23/2023 at 920AM, Licensing Program Analysts (LPAs) L. Fici and L. Fontanilla arrived unannounced to conduct a 10-day initial complaint investigation visit on the above allegation. LPAs met with Carlos Advincula and explained the purpose of visit. Shortly after, at 10:10AM, Amelia Alfonso Administrator (ADM) arrived to the facility.

During the visit, LPAs interviewed One (1) of Five (5) clients and attempted to interview C2. LPAs interviewed Three (3) staff. LPAs obtained the following documents: Current staff schedule, Physician's Report, Individual Service Plan (ISP), Individual Program Plan (IPP), Clients roster and LIC500.

It was alleged that: Facility not providing adequate staffing for clients in care. During Interviews conducted. All staff interviewed state that there are two (2) to three (3) care staff during the day Mondays though Sundays. During the night shift from 10:00PM to 6:00AM, there is one care staff in the facility. C1 stated Monday through Sunday there are two (2) to three (3) staff in the facility and during the night shift, there is one (1) staff from 10:00pm through 6:00AM.



Continue on Lic9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
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 2
Control Number 15-AS-20230320102453
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: KRISTA & KRIS CORPORATION
FACILITY NUMBER: 019201180
VISIT DATE: 03/23/2023
NARRATIVE
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Continued from Lic9099

During record review, LPAs confirmed and it was indicated on the facility staff schedule that there is a care staff during the morning shift from 6:00AM through 8:00AM Monday through Sunday. A second staff comes in at 8:00AM. Facility only has one client that attends the day program. LPAs observed facility staff schedule which indicated that there is enough staff working in the facility all week to be able to care for the needs for the clients.

Based on Interviews record review conducted, the above allegation is unsubstantiated. 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, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with ADM and copy of this report was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2