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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201180
Report Date: 09/23/2022
Date Signed: 09/23/2022 01:39:21 PM

Document Has Been Signed on 09/23/2022 01:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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:
09/23/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH: Amelia Alfonso, AdministratorTIME COMPLETED:
01:40 PM
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On 09/23/2022 at 1:05 PM, Licensing Program Analyst (LPA) L. Fici and Licensing Program Manager (LPM) Y. Flores-Larios arrived unannounced to conduct a Pre-licensing Visit. LPA and LPM met with, Amelia Alfonso, Administrator (ADM) and explained the purpose of the visit. The facility currently has 5 clients who reside in the facility.

LPA and LPM toured facility with ADM, including but not limited to 2 bedrooms, 4 bathrooms, kitchen, common areas and backyard. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars and non-skid matts. Linens and hygiene supplies were observed inside a cabinet. There is sufficient lighting throughout facility. Room temperature was maintained at 79 degrees F and hot water temperature was maintained at 106.7 degrees F. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 1/21/2022.

No issues noted during inspection. LPA and LPM observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted with administrator and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2022
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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