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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001495
Report Date: 08/10/2022
Date Signed: 08/10/2022 11:56:42 AM

Document Has Been Signed on 08/10/2022 11:56 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
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
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Amy CookTIME COMPLETED:
12:15 PM
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On 8/10/2022, Licensing Program Analyst (LPA) Avila arrived to conduct a complaint visit. While LPA was at the facility LPA toured the kitchen to ensure food that was on the menu was present. LPA observed expired bacon as of June 2022, bagged cole slaw that had expired and was brown and had liquified. LPA observed packaged roast beef that was expired July 2022 and an open bag of hot dogs that was not sealed, wrapped with a rubber band and had white fussy spots. LPA handed food to staff (S1) present who discarded it.

S1 provided LPA with the Menu which did not contain dates and stated for Wednesday mornings Breakfast is potatoes, hot dog slices burrito, orange juice and milk. S1 said bacon and cereal was served this morning. Snack listed on menu was "apple/banana." S1 and licensee could not produce bananas.

80076 Food Services
(b) The licensing agency shall have the authority to require the facility to provide written information, including menus, regarding the food purchased and used over a given period when it is necessary to determine if the licensee is in compliance with the food service requirements in the regulations in this Division. (1)The licensing agency shall specify in writing the written information required from the licensee.

CCLD is requesting the following which are due every Friday through September 2022:
1. Accurate weekly menu's from July 2022 through September 2022.
2. Receipts to show food purchased match menus and alternates

The following deficiencies were cited per Title 22 of the California Code of Regulation (809D). 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.
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/10/2022 11:56 AM - It Cannot Be Edited


Created By: Jaclyn Avila On 08/10/2022 at 10:49 AM
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
, 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
80076(a)(1)

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80076(a)(1) Food Services- In facilities providing meals to clients, the following shall apply:All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients...
This requirement is not met as evidenced by: Based upon observation, interview and documentation the
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The licensee agrees to remove expired food and agrees to conduct a by weekly audit of food to ensure it is safe to serve. A sign off sheet that will be utilized will be provided by COB on 8/11/2022 to CCL.
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Licensee failed to keep the food safe and of the quality necessary for 5 of 5 clients in care.

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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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