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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200307
Report Date: 04/16/2024
Date Signed: 04/16/2024 02:51:53 PM

Document Has Been Signed on 04/16/2024 02:51 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 SERVICESFACILITY NUMBER:
079200307
ADMINISTRATOR/
DIRECTOR:		ANNA LISA G. LAZAROFACILITY TYPE:
735
ADDRESS:748 SEACLIFF COURTTELEPHONE:
(510) 541-5234
CITY:RODEOSTATE: CAZIP CODE:
94572
CAPACITY: 6CENSUS: 6DATE:
04/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:25 PM
MET WITH:Anna Lisa Lazaro, CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On 4/21/2023 at 9:50AM, Licensing Program Analyst (LPA) C. Fowler arrived to conducted an unannounced 1-Year Required inspection. LPA met with Caregiver, Lisa Soriano and explained the purpose of the visit. Administrator, Anna Lisa Lazaro arrived at 12:45PM LPA explained the purpose of the visit. The Administrator currently holds a certificate (#6005651735) that expires on 10/30/2025, 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 68 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 105.8 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 05/26/2023. Emergency Disaster Plan was last posted on 04/16/2024. First aid kit was observed to be complete. Fire drill was last conducted on 04/7/2024.

Continued on LIC809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2024
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: 04/16/2024
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Continue from LIC 809

Three (3) staff records were reviewed, and all staff have criminal record clearance and holds a current first aid/CPR certificate. Four (4) Clients records were reviewed all found to be complete.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 04/26/2024:

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


Exit interview conducted, a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024
LIC809 (FAS) - (06/04)
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