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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001495
Report Date: 10/24/2023
Date Signed: 10/24/2023 04:15:00 PM

Document Has Been Signed on 10/24/2023 04:15 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:VILLA KRISTINAFACILITY NUMBER:
045001495
ADMINISTRATOR:COOK, AMYFACILITY TYPE:
735
ADDRESS:83 SKYMOUNTAIN CIRCLETELEPHONE:
(530) 809-4371
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY: 4CENSUS: 4DATE:
10/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:TIME COMPLETED:
04:30 PM
NARRATIVE
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On 10/24/2023, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Amy Cook and explained the purpose of the visit.

LPA Boyles and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, garage, backyard, and common restrooms. LPA observed the facility to be clean, in good repair and odor-free and each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids. Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. Hot water temperature was measured at 108 F. LPA observed one (1) fire extinguishers, fire detectors, and carbon monoxide detectors.

LPA reviewed a total of four (4) residents' files and three (3) staff files. Two of the three staff files have missing TB testing. One staff file had missing criminal clearance.

Several topics were discussed.

California Code of Regulations,(Title 22), is being cited on the attached LIC809D. A civil penalty for $100 per day for a maximum of 5 days, totaling $500 for criminal record clearance violation is being assessed on the attached LIC 421BG.



An exit interview was conducted, and Plans of Corrections were reviewed and developed with the Administrator. A copy of this report, LIC 809-D, LIC421BG, and Appeal Rights were discussed and provided to Administrator.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 10/24/2023 04:15 PM - It Cannot Be Edited


Created By: Jaynae Boyles On 10/24/2023 at 03:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: VILLA KRISTINA
FACILITY NUMBER: 045001495

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews and record review, the licensee did not comply with the section cited above in 1 out of 3 staff file reviews and the Administrator reported to the LPA that the paperwork did not get sent which revealed that not all staff have a criminal clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
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The Administrator will fax the transfer of criminal record clearance for the staff missing the criminal clearance. Furthermore, the Administrator will not allow staff to begin work until criminally cleared or a transfer of the criminal clearance is completed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Lauren Crocker
LICENSING EVALUATOR NAME:Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/24/2023 04:15 PM - It Cannot Be Edited


Created By: Jaynae Boyles On 10/24/2023 at 03:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: VILLA KRISTINA
FACILITY NUMBER: 045001495

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 3 staff file reviews did not have these required documents which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
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The Administrator will ensure that all staff have a Tuberculosis test and documents on file at the facility. Furthermore, the Administrator will not allow staff to begin work until Tuberculosis test documents are completed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Lauren Crocker
LICENSING EVALUATOR NAME:Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023


LIC809 (FAS) - (06/04)
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