019201180-4-4-2023-15-AS-KHOS-CQUMFU-20230413093454

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201180
Report Date: 04/04/2023
Date Signed: 04/04/2023 12:50:55 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
03/30/2023 and conducted by Evaluator Liridon Fici

COMPLAINT CONTROL NUMBER: 15-AS-20230330114030

FACILITY NAME:	KRISTA & KRIS CORPORATION		FACILITY NUMBER:	019201180
ADMINISTRATOR:	ALFONSO, AMELIA		FACILITY TYPE:	735
ADDRESS:	5541 ROOSEVELT PLACE		TELEPHONE:	(650) 255-9603
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY:	6	CENSUS: 5	DATE:	04/04/2023
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Care staff, Carlos Advincula		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Staff disclosed confidential information to other clients.

INVESTIGATION FINDINGS:

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On 4/4/2023 at 10:40 AM, Licensing Program Analysts (LPAs) L. Fici and L. Hall arrived unannounced to conduct a initial 10-day open complaint investigation visit on the above allegation. LPAs met with Care staff Carlos Advincula and explained the purpose of visit. At 11:36 AM, ALFONSO, AMELIA- Administrator (ADM) arrived to the facility.

During today's visit, LPAs interviewed Two (2) of Five (5) clients and Four (4) staff members. LPAs obtained the following documents: Quarterly reports for three (3) of five (5) clients and medical health lab results for C1.

Continue on Lic9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

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-20230330114030

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: 04/04/2023

NARRATIVE

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Continued from Lic9099

Based on interviews conducted, all four (4) staff members stated they were not aware of any confidential information being disclosed between staff and clients or client to client. During interview with C1 and C2, both stated S4 disclosed confidential information about a client to a client.

Based on LPAs interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC9099-D.

Exit interview conducted with ADM, and a copy of this report provided along with appeal rights.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20230330114030

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: 04/04/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/11/2023 Section Cited CCR 80072(a)(1)	1 2 3 4 5 6 7	80072(a)(1) Personal Rights: (a) Except for children’s residential facilities, each client shall have personal rights... (1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to conduct in-service training with all staff members and a self-certification on section 80072- Personal Rights and to submit a to CCL by POC due date.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the section cited above by disclosing confidential information about another client 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.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

LIC9099 (FAS) - (06/04)

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