079200307-4-21-2023-15-AS-CFOR-CR4TB5-20230421143433

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200307
Report Date: 04/21/2023
Date Signed: 04/21/2023 02:34:44 PM

Document Has Been Signed on 04/21/2023 02:34 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	CHRISJELL ADULT CARE SERVICES		FACILITY NUMBER:	079200307
ADMINISTRATOR:	ANNA LISA G. LAZARO		FACILITY TYPE:	735
ADDRESS:	748 SEACLIFF COURT		TELEPHONE:	(510) 541-5234
CITY:	RODEO	STATE: CA	ZIP CODE:	94572
CAPACITY: 6		CENSUS: 6	DATE:	04/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Anna Lisa Lazaro, Administrator		TIME COMPLETED:	02:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 4/21/2023 at 9:50AM, Licensing Program Analyst (LPA) C. Fowler arrived to conducted an unannounced 1-Year Required inspection. No one was at the facility clients were at day program Administrator, Anna Lisa Lazaro arrived 10:50AM LPA explained the purpose of the visit. The Administrator currently holds a certificate (#6005651735) that expires on 10/30/2023, The facility’s fire clearance was approved for six (6) ambulatory clients. LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of four (5) total bedrooms which four (4) bedrooms are occupied by clients, and (1) one staff room. There are two (2) full bathrooms. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature is maintained at 65 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hot water temperature in the shared clients’ bathroom was measured at 105.1 degrees Fahrenheit. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 06/22/2022. Emergency Disaster Plan was last posted on 04/21/2023. First aid kit was observed to be complete. Fire drill was last conducted on 02/13/2023. Continued on LIC809C

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CHRISJELL ADULT CARE SERVICES	FACILITY NUMBER: 079200307
	VISIT DATE: 04/21/2023

NARRATIVE

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Five (5) staff records were reviewed, and all staff have criminal record clearance and holds a current first aid certificate. Five (5) Clients records were reviewed.

LPA observed the following deficiencies:

At 11:41AM, LPA observed 2 rooms located in the garage that are not on the facility sketch.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 04/28/2023:

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

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.

Exit interview conducted. A copy of appeal rights and this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/21/2023 02:34 PM - It Cannot Be Edited

Created By: Carol Fowler On 04/21/2023 at 12:36 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CHRISJELL ADULT CARE SERVICES	FACILITY NUMBER: 079200307
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85087(a)(3)(A)

Building and Grounds

(3) No room commonly used for other purposes shall be used as a bedroom for any person. (A) Such rooms shall include but not be limited to halls, stairways, unfinished attics or basements, garages, storage areas, and sheds, or similar detached buildings. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by creating rooms in the garage which poses a potential health and safety risk to persons in care.
	POC Due Date: 05/22/2023
	Plan of Correction
1 2 3 4	ADMINISTRATOR SHALL 1) PROVIDE EVIDENCE OF CITY APPROVAL FOR ALTERATIONS 2) PROVIDE CITY PERMITS AND 3) SUBMIT LIC 200 WITH UPDATED FACILITY SKETCH AND PERMITS 4) CCL WILL ORDER FIRE CLEARANCE UPON APPROVAL.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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:

Bennett Fong

LICENSING EVALUATOR NAME:

Carol Fowler

LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

LIC809 (FAS) - (06/04)

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