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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601076
Report Date: 07/07/2021
Date Signed: 07/07/2021 06:07:40 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:CRISTINA'S CARE HOMEFACILITY NUMBER:
415601076
ADMINISTRATOR:MADRIGAL, OSCARFACILITY TYPE:
740
ADDRESS:1450 GREENWOOD WAYTELEPHONE:
(650) 952-6641
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: 5DATE:
07/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Oscar MadrigalTIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Gladys Kuizon conducted an annual inspection today and met with Administrator Oscar Madrigal.

LPA entered the facility through the facility's central entry point. At 11:51 AM, a tour of the facility was conducted. The facility's screening procedures were reviewed. COVID-19 postings including hand-washing and infection control guides were observed throughout the facility including on the main entrance, hallways, and bathrooms. Staff were observed wearing face coverings. Residents were observed in their respective bedrooms.

The facility has a supply of personal protective equipment (PPE) including face shields, isolation gowns, gloves, and face masks. Hand sanitizers, soap, and paper supplies were observed available. At least 2 days' supply of perishable food and at least 1 week's supply on non-perishable food supply was observed in the premises.

Per Administrator, all residents and staff are fully vaccinated against COVID-19. The facility is currently accepting visitors inside the facility. Screening procedures including temperature and symptom checking and logging is in place.

Exit routes were observed clear and unobstructed. The facility equipped with smoke detectors, fire extinguishers, and a carbon monoxide detector. Resident roster with current emergency contact information is available.

No deficiencies were cited. Exit interview conducted with Administrator and a copy of this report was provided during visit.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
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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