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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001495
Report Date: 09/23/2024
Date Signed: 09/23/2024 01:26:05 PM

Document Has Been Signed on 09/23/2024 01:26 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/
DIRECTOR:		MABEL, MAXINEFACILITY TYPE:
735
ADDRESS:83 SKYMOUNTAIN CIRCLETELEPHONE:
(530) 399-0180
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY: 4CENSUS: 4DATE:
09/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Licensee, Romelina CookTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On September 23, 2024 at approximately 11:15 AM, Licensing Program Analyst (LPA), Farhaan Sarangi and Investigator, Drew Mitchell from the Community Care Licensing-Investigations Branch (IB) arrived unannounced at Villa Kristina for the purpose of conducting a Required 1 Year inspection. LPA and Investigator were greeted at the door by Caregiver, Vanessa Ngiralemau, and was granted access into the facility. Licensee, Romelina Cook arrived 30 minutes later.

LPA, Investigator, and Licensee toured the facility. LPA and Investigator observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on March 2024 at the time of the inspection. All smoke and Carbon Monoxide Detectors were tested and found to be operational during the inspection. Water temperature in facility bathroom measured at 105 degrees, within acceptable range of 105 to 120 degrees F. LPA and Investigator observed sufficient perishable and non-perishable foods located in the kitchen. There are special provisions made for individuals with special dietary needs. Food menu was presently available for viewing during the inspection. Medications were centrally stored and locked. Cleaning products and other toxins are located in the laundry room that was inaccessible to clients in care. There was a supply of linens, cleaners, hygiene products and paper products available for clients. All bathrooms designated for clients in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms in clients rooms have a towel and soap. A tour of client bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing. LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms of COVID-19 or other infectious diseases are present in the facility. First Aid kit was inspected and found to be appropriate during the inspection. Emergency Disaster Drill was last conducted in September 2023 (See LIC 9102-Technical Advisory). LPA and Investigator reviewed the Emergency Disaster Drill document and noticed that the last drill was conducted on September 3, 2023. (Report continued on LIC 809C)
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2024
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: VILLA KRISTINA
FACILITY NUMBER: 045001495
VISIT DATE: 09/23/2024
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LPA and Investigator educated the Licensee on the importance of ensuring that the Emergency Disaster Drills are conducted in accordance with Title 22 regulations.

LPA reviewed 4 of 4 client files. Medication Orders were reviewed and found to be not in order (See LIC 9102-Technical Violation) LPA educated the Administrator on the importance of ensuring that ALL Medication Orders are kept in order and reviewed by staff members.

LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308- Designation of Facility Responsibility
LIC 309- Administrative Organization
Most up-to-date Liability insurance
Control of Property
Register of clients

No deficiencies were cited during this Required 1 year inspection. Exit interview was conducted and a copy of this report was signed and given to the Licensee.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
LIC809 (FAS) - (06/04)
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