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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201180
Report Date: 10/31/2024
Date Signed: 10/31/2024 03:57:05 PM

Document Has Been Signed on 10/31/2024 03:57 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/
DIRECTOR:		ALFONSO, AMELIAFACILITY TYPE:
735
ADDRESS:5541 ROOSEVELT PLACETELEPHONE:
(650) 255-9603
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 6CENSUS: 5DATE:
10/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Amelia Alfonso, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:05 PM
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On 10/31/2024 at 2:30 PM, Licensing Program Analysts (LPAs) P. Manalo and J. Clancy-Czuleger arrived unannounced to conduct 1 Year Annual Required inspection. LPAs met with Administrator, Amelia Alfonso and explained the purpose of the visit. The facility’s fire clearance was approved for six (6) ambulatory only.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which 4 bedrooms are occupied by the clients. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 75 degree Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 107.6 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene's was available for clients. There is a minimum of one week supply of nonperishable and 2 day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 02/20/2024. Emergency Disaster Drill was last posted on 07/15/2024.

At 2:45pm, 5 of clients records were reviewed. At 3:10pm, 3 staff records were reviewed and 3 of 3 have current first aid training and 3 of 3 associated to the facility.

Continue to LIC809-C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2024
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: 10/31/2024
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Continue from LIC809-C...

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 11/08/2024 :

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610E Emergency Disaster Plan

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC809 (FAS) - (06/04)
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