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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201180
Report Date: 08/19/2024
Date Signed: 08/19/2024 10:33:31 AM

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
08/12/2024 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20240812141256
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:
08/19/2024
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Amy Alfonso, Administrator TIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Staff physically assaulted client in care
INVESTIGATION FINDINGS:
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 On 08/19/2024 at 08:45 AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger and P. Manalo arrived unannounced to conduct a complaint visit. LPA explained the purpose of the visit with staff and Administrator Amy Alfonso was called and joined us later.

During the initial 10-day complaint visit LPA interviewed staff and resident and witnesses. LPAs collected resident roster, staff roster, consumer notes and a copy of the SIR.

On the allegation: Staff physically assaulted client in care. R1 had originally described to W1 that S1 poked my head mimicking/ doing the hand gesture of poking his head. Later during his quarterly meeting R1 described it as a punch to his head and upper body.

Continued on LIC 9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
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-20240812141256
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: 08/19/2024
NARRATIVE
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...Continued from LIC 9099

W1 stated she does believe an altercation happened, but she does not believe that S1 punched R1. S2 described the situation stating S1 was sitting at the table facing the room with her back to the wall, R1 was across the room from her. R1 was told that his dad was outside. When he got up, he turned to S1 and spit at her over the table from across the room two times.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.



SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2