<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201180
Report Date: 03/23/2023
Date Signed: 03/23/2023 01:20:49 PM

Substantiated


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
02/27/2023 and conducted by Evaluator Liridon Fici
COMPLAINT CONTROL NUMBER: 15-AS-20230227110004
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:
12:40 PM
MET WITH:Carlos Advincula- Care StaffTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not ensuring there is food in the facility for clients.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 3/23/2023 at 12:40 PM, Licensing Program Analysts (LPAs) L. Fici and L. Fontanilla arrived unannounced to conduct a subsequent complaint investigation visit on the above allegation. LPAs were greeted by Amelia Alfonso, Administrator and explained the purpose of this visit.

During the course of the investigation, LPAs obtained the following documents: Medication Administration Record (January 2023, February 2023, March 2023), food menu, client and staff roster, progress notes (February 2023) and LIC500. LPAs interviewed two (2) of Five (5) clients and six (6) staff.

It was alleged that: Staff are not ensuring there is food in the facility for clients.



Continue on Lic9099-C




Substantiated
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 3
Control Number 15-AS-20230227110004
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continue from Lic9099

On 3/9/2023, LPAs L. Fici and L. Hall conducted initial 10-day investigation. During the visit, LPAs observed facility was low on both perishable and nonperishable foods.

Based on LPAs observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations is found to be Substantiated.

Deficiency were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview was conducted with care staff, and a copy of this report was provided along with appeal rights.
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 3
Control Number 15-AS-20230227110004
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/23/2023
Section Cited
CCR
85076(d)(1)
1
2
3
4
5
6
7
85076(d)(1)- Food Service
(d) The licensee shall meet the following food supply and storage requirements:(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.
1
2
3
4
5
6
7
On 3/23/2023, LPAs observed there is a sufficient amount of 2-day perishable and 7-day non-perishable food supply.

Deficiency is cleared.

8
9
10
11
12
13
14
This requirement is not met as evidenced by:
Based on observation, the licensee did not comply with the section cited above by not maintaining a sufficient 2-day perishable and 7-day non-perishable food supply in the facility for clients which poses/posed a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3