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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003672
Report Date: 07/31/2024
Date Signed: 07/31/2024 12:36:37 PM

Document Has Been Signed on 07/31/2024 12:36 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CRISTOBAL HOMES IIIFACILITY NUMBER:
306003672
ADMINISTRATOR/
DIRECTOR:		NERISSA CRISTOBALFACILITY TYPE:
735
ADDRESS:2624 COOLIDGE AVENUETELEPHONE:
(714) 912-4505
CITY:ORANGESTATE: CAZIP CODE:
92867
CAPACITY: 6CENSUS: 5DATE:
07/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Nerissa CristobolTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
NARRATIVE
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On July 31, 2024 at 8:45AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Administrator (AD) Nerissa Cristobol and explained the purpose of the visit.

The facility is licensed to operate for six (6) ambulatory clients. The facility is a single-story structure located in a residential neighborhood. It consists of the following: three shared client bedrooms, 1 staff bedroom, two (2) bathrooms, attached garage, living room, dining room, kitchen, detached storage room in the backyard, and outdoor covered patio area.

LPA Kim toured inside and outside of the physical plant. There are no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each client’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All bedrooms were inspected: Client Room 1, Client Room 2, Client Room 3, and Staff Room 1. Bathrooms were found to be clean and operational. The water temperature measured at 118 degrees F at the client's bathroom. A comfortable temperature of 78 degrees F was maintained in the facility.

LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency Food, Emergency Water, and Emergency supplies for the clients are stored in the garage and dining area, The facility has smoke detectors and carbon monoxide detectors that were operable. First Aid Kit contained all the necessary elements. The Facility has one (1) fire extinguisher that is fully charged and was serviced May 9, 2024.

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CRISTOBAL HOMES III
FACILITY NUMBER: 306003672
VISIT DATE: 07/31/2024
NARRATIVE
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During the visit, LPA Kim observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and clients, and sanitizing stations in common areas. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA Kim conducted an audit of five (5) clients (C1-C5) files, two (2) staff #1-#2 personnel files, and medication and medication administration record that were all in order and complete. LPA conducted two (2) staff interviews.

According to the California Code of Regulations (Title 22, Division 6, Chapter 1) deficiencies has been observed and citations issued. A Technical violation was assessed during this inspection visit according to the California Code of Regulations (Title 22, Division 6, Chapter 1).

An exit interview was conducted, and a copy of this report and appeal rights LIC 9058 was provided to Administrator Nerissa Cristobol.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024
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Document Has Been Signed on 07/31/2024 12:36 PM - It Cannot Be Edited


Created By: Edward Kim On 07/31/2024 at 12:11 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CRISTOBAL HOMES III
FACILITY NUMBER: 306003672

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80073(a)
Telephones
(a) All facilities shall have telephone service on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPA observed when attempting to call the facility landline, the phone was not working. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2024
Plan of Correction
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Licensee called AT&T and will receive a new device to fix the phone issue. The order was placed and an email copy of the order was sent to CCLD via email edward.kim@dss.ca.gov on July, 31, 2024. Licensee will email CCLD to edward.kim@dss.ca.gov when device arrives and is in working order.
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:Lourdes Montoya
LICENSING EVALUATOR NAME:Edward Kim
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/31/2024 12:36 PM - It Cannot Be Edited


Created By: Edward Kim On 07/31/2024 at 12:11 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CRISTOBAL HOMES III
FACILITY NUMBER: 306003672

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(e)
Safeguards for Cash Resources, Personal Property and Valuables
(e) Cash resources, personal property, and valuables of clients shall be separate and intact, and shall not be commingled with facility funds or petty cash.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, and interview, the licensee did not comply with the section cited above. LPA observed C2 balance difference being over $3.82 and C4 balance being over $38.03. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2024
Plan of Correction
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Licensee states they will balance the C2 and C4 P&I funds and send proof of completed and correct balance on LIC 405 POC to CCLD via email to edward.kim@dss.ca.gov by POC due date 8/15/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lourdes Montoya
LICENSING EVALUATOR NAME:Edward Kim
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024


LIC809 (FAS) - (06/04)
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