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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202192
Report Date: 07/17/2023
Date Signed: 08/18/2023 10:37:32 AM


Document Has Been Signed on 08/18/2023 10:37 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
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:CRISTINE'S GUEST HOME IIFACILITY NUMBER:
275202192
ADMINISTRATOR:MA CRISTINA DEL ROSARIOFACILITY TYPE:
740
ADDRESS:852 ANTIGUA AVENUETELEPHONE:
(831) 998-8162
CITY:SALINASSTATE: CAZIP CODE:
93905
CAPACITY:6CENSUS: 6DATE:
07/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Joe Del Rosario TIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Administrator, Joe Del Rosario, Continual Administrator's Certification expires 06/05/2023. There are currently 6 residents who reside at this home and there is 0 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, medication storage, kitchen, garage and outdoor areas. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguisher is within the safety regulation period.

LPA Hurt observed possible black mold in the window sills of two separate facility bedrooms (Bedroom #1 and Bedroom #2). LPA Hurt observed resident bedroom blinds covering windows to be broken. LPA Hurt sliding glass door leading to backyard has no window screen. LPA Hurt observed the facility resident bedroom carpets to be stained, and dirty. LPA Hurt observed the facility kitchen to be filled with clutter including a broken television on the dining table. LPA Hurt observed several facility bedroom windows do not have screens. LPA Hurt observed the facility kitchen to have several refrigerators each having moldy food, and food inside containers with no date or label. LPA Hurt the Centrally Stored Medication Logs do not have Resident 1's current medications logged.

The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Facility Staff Lerma Domingo and copy of report left at facility
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023
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


Document Has Been Signed on 08/18/2023 10:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: CRISTINE'S GUEST HOME II
FACILITY NUMBER: 275202192

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(d)(2)
87303 Personal Accommodations and Services
(d) The following space and safety provisions shall apply to all facilities:
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.
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 in LPA Hurt observed facility Room #1, and Room #2 to have possible black mold in the window sill that has not been tested which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2023
Plan of Correction
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Licensee will remove Residents from facility Bedroom #1 and Bedroom #2 until black substance inside the window sill is tested, and removed.
Type A
Section Cited
CCR
87465(6)
87465
Incidental Medical and Dental Care

(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:
(A) The name of the resident for whom prescribed.
(B) The name of the prescribing physician.
(C) The drug name, strength and quantity.
(D) The date filled.
(E) The prescription number and the name of the issuing pharmacy.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in LPA Hurt observed Resident 1's medication dated 06/15/2023 was not documented in the Centrally Stored Medication Log which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2023
Plan of Correction
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Licensee agrees to provide training from an outside source on proper Medication Distribution including documenting medications by 07/18/2023.
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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 08/18/2023 10:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: CRISTINE'S GUEST HOME II
FACILITY NUMBER: 275202192

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)

87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.


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 in LPA Hurt observed the facility to be malodorous, carpet in bedrooms is staune which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2023
Plan of Correction
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Licensee agreed to deep clean the facility kitchen, bedrooms, and common areas and send proof to LPA by POC date of 07/31/2023.
Type B
Section Cited
CCR
87465(8)
87465
Incidental Medical and Dental Care
(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following:
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 in LPA Hurt observed the facility does not have a complete first aid kit, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2023
Plan of Correction
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Licensee agrees to provide a complete first aid kit and send proof to LPA Hurt by POC date of 07/31/2023.
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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 08/18/2023 10:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: CRISTINE'S GUEST HOME II
FACILITY NUMBER: 275202192

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(9)
(9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.

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 in LPA Hurt observed the facility krefrigerators to be dirty, and contain food with mold, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2023
Plan of Correction
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Licensee agrees to deep clean facility refrigerators, conduct training with facility staff on safe food preparation, and send proof to LPA by POC date of 07/31/2023.
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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4