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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045001495
Report Date: 08/10/2022
Date Signed: 08/10/2022 11:54:59 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/04/2022 and conducted by Evaluator Jaclyn Avila
COMPLAINT CONTROL NUMBER: 25-AS-20220804090916
FACILITY NAME:VILLA KRISTINAFACILITY NUMBER:
045001495
ADMINISTRATOR:COOK, AMYFACILITY TYPE:
735
ADDRESS:83 SKYMOUNTAIN CIRCLETELEPHONE:
(530) 809-4371
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:6CENSUS: 5DATE:
08/10/2022
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Amy CookTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Unlawful Eviction
INVESTIGATION FINDINGS:
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The Department met with Amy Cook, Administrator unannounced regarding the allegation above. Licensing Program Analyst (LPA) Jaclyn Avila completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. LPA Avila ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95.
This Department has investigated and found the above allegation. The Department reviewed the eviction notice issued to client on 8/1/2022, which did not provide specific facts and dates. Licensee could not produce documentation that the client was responsible for paying for basic services. The admission agreement signed by the client on 4/24/2015 states the regional center is responsible for paying for basic services.
Based on LPAs observations, document review and interviews the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), are being cited on the attached LIC 9099D. Appeal Rights were explained and provided to the facility representative listed above and an Exit Interview was conducted. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Jaclyn Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
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 25-AS-20220804090916
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: VILLA KRISTINA
FACILITY NUMBER: 045001495
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/11/2022
Section Cited
CCR
85068.5(c)
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85068.5 Eviction Procedures-(c) The licensee shall set forth in the notice to quit the reasons for the eviction, with specific facts including the date, place, witnesses, and circumstances.
This requirement is not met as evidenced by: Based upon interview and document review
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Licensee agrees to rescind the eviction notice today in writing to client and will provide CCL with a copy signed by client that client has an understanding the eviction notice is being rescinded.
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the Licensee failed to provide specific facts related to client failing to pay for basic services.

This poses an immediate Health, Safety and/or Personal Rights risk to clients in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Jaclyn Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3