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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201180
Report Date: 09/08/2023
Date Signed: 09/08/2023 12:44:19 PM

Document Has Been Signed on 09/08/2023 12:44 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
OAKLAND ASC, 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:
09/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:ALFONSO, AMELIA, LicenseeTIME COMPLETED:
12:55 PM
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On 9/8/2023 starting at 9:00 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct 1-Year Annual Required Inspection. LPA met with Alfonso, Amelia, Licensee and explained the purpose of the visit. Administrators certificate (6021617735) is valid and expires on 10/28/2024. The facility’s fire clearance was approved for all six (6) ambulatory clients. Upon entry, LPA observed two (2) staff and one (1) client present during inspection.

Starting at 9:48 AM, LPA toured facility with Licensee including but not limited to four (4) bedrooms, two (2) bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which 3 bedrooms are private, and one room is shared. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 74 Degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients'. The hot water temperature in clients’ common area bathroom was measured at 107.4 Degrees Fahrenheit. There is a minimum of one-week supply of nonperishable and 2-day supply of perishable foods. Sharps and toxins were locked and inaccessible to clients'.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was observed last serviced on 2/21/2023. First aid kit was observed to be complete.


Continue on Lic809-C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: KRISTA & KRIS CORPORATION
FACILITY NUMBER: 019201180
VISIT DATE: 09/08/2023
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Continued from Lic809

Starting At 10:35 AM, LPA reviewed 3 of 3 staff records. At 10:55 AM, LPA reviewed 5 of 5 clients' record. At 11:50 AM, LPA reviewed a sample of 5 of 5 clients' medications.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 9/15/2023:

· LIC 308 Designation of Administrative Responsibility
· LIC 500 Personnel Report
· LIC 610D Emergency Disaster Plan (9 Pages)
· Liability Insurance
· Surety bond



No deficiencies cited during visit.



Exit interview conducted with Licensee, and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC809 (FAS) - (06/04)
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