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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603722
Report Date: 03/25/2025
Date Signed: 04/07/2025 03:46:58 PM

Document Has Been Signed on 04/07/2025 03:46 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CRISJADE HOME, LLCFACILITY NUMBER:
198603722
ADMINISTRATOR/
DIRECTOR:		LOSOYA, MARTHAFACILITY TYPE:
735
ADDRESS:14736 FIGUERAS RDTELEPHONE:
(657) 239-0013
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 4CENSUS: 0DATE:
03/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:17 AM
MET WITH:Loida Samonte TIME VISIT/
INSPECTION COMPLETED:
11:02 AM
NARRATIVE
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Loida Samonte, owner of the home, and explained the purpose of the visit. There are currently no clients residing in the facility.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

· LPA observed that the facility has a completed infection control plan.



Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood that is licensed for a capacity of four (4) ambulatory clients between the ages of eighteen (18) through fifty-nine (59). It consists of four (4) client bedrooms, a kitchen, a living room, a dining room, an attached garage that contains extra supplies for the facility, a backyard with shaded area with a locked storage shed that contains tools, and two (2) client restroom which had a hot water temperature reading of 105.9 and 106.7 Degrees Fahrenheit respectively. Knives along with the chemicals and cleaning supplies will be kept locked and inaccessible to clients.


· The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. There are no pools are or bodies of water accessible to the clients. Fire alarm system and carbon monoxide detectors are operational. The facility has two (2) fully charged fire extinguishers that are kept in the facility.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2025
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
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CRISJADE HOME, LLC
FACILITY NUMBER: 198603722
VISIT DATE: 03/25/2025
NARRATIVE
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Operational Requirements:

· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for four (4) ambulatory clients between the ages of 18 – 59.


· Care and supervision to meet the clients’ needs was observed.

Staffing:

· There are not staff working at the home currently because no clients are living in the home at the moment.

Personnel Records/Staff Training:

· Administrator’s certificate is pending according to the Administrator’s Certification Bureau.


· No staff records are available for review because none are currently working in this home.

Client Rights/Information:

· No clients resident in the home and therefore there were no physicians orders or medications to review.

Client Records/Incident Reports:

· Because no clients live in the home there are no client records to be reviewed today.

Food Service:

· The kitchen was inspected and the food preparation area, and storage areas were observed to be clean and sanitary. A seven (7) day supply of non-perishable food and two (2) day supply of perishable foods were observed in the kitchen.



Health Related Services:

· No client medications had to be reviewed as the home does not have any clients currently.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CRISJADE HOME, LLC
FACILITY NUMBER: 198603722
VISIT DATE: 03/25/2025
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Incidental Medical and Dental:

· There was no staff training to review during today’s visit as there is no staff working the home.

Disaster Preparedness, and Emergency Intervention:

· An Emergency Disaster Plan LIC610D is kept in the facility.



Emergency Intervention:

· No manual restraints or seclusion are used with clients in care.



Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed. Exit interview held and a copy of the report were provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4