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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200307
Report Date: 03/04/2025
Date Signed: 03/04/2025 04:10:13 PM

Document Has Been Signed on 03/04/2025 04:10 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:
03/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:ELIZABETH SORIANO, CARE STAFFTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 3/04/2025 at 1:00PM, Licensing Program Analysts (LPAs) Carol Fowler and Yasamin Brown 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 1:30PM LPAs explained the purpose of the visit. The Administrator currently holds a certificate (#7001515735) that expires on 10/30/2025, The facility’s fire clearance was approved for six (6) ambulatory clients.

LPAs 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 105.2 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 07/10/2024. Emergency Disaster Plan was last posted on 04/16/2024. First aid kit was observed to be complete. Fire drill was last conducted on 01/6/2025.

Continued on LIC809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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 03/04/2025 04:10 PM - It Cannot Be Edited


Created By: Carol Fowler On 03/04/2025 at 03:34 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: 03/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having medication in a unlocked drawer located in the kitchen which poses an immediate health and safety to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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Administrator locked the medication in the medication cabinet. DEFICIENCY CLEARED DURING VISIT.
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:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


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: 03/04/2025
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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.

LPA observed the following deficiencies:
  • At 2:10PM, LPAs observed unlocked medication (Incruse Ellipta) in a drawer located in the kitchen.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 03/13/2025:

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: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC809 (FAS) - (06/04)
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