415601076-11-8-2023-14-AS-KHOS-CY2M3D-20231129081457

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601076
Report Date: 11/08/2023
Date Signed: 11/08/2023 12:42:57 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/02/2023 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20231102111838

FACILITY NAME:	CRISTINA'S CARE HOME		FACILITY NUMBER:	415601076
ADMINISTRATOR:	MADRIGAL, OSCAR		FACILITY TYPE:	740
ADDRESS:	1450 GREENWOOD WAY		TELEPHONE:	(650) 952-6641
CITY:	SAN BRUNO	STATE: CA	ZIP CODE:	94066
CAPACITY:	6	CENSUS: 5	DATE:	11/08/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	House Manager, Winnie Coronel		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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Staff do not ensure facility is free from hazards

INVESTIGATION FINDINGS:

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On November 8, 2023, Licensing Program Analyst (LPA) conducted an unannounced complaint visit. LPA met with house manager, Winnie Coronel and explained the purpose of the visit.

Regarding to allegation of staff do not ensure facility is free from hazards, the reporting party stated that the facility re-furbished the deck and resulted nails protruding from the wooden floor slabs, uneven wooden floor slabs and the ramp from the family room into the deck has a mental plate on each side to create an even surface which was just a "band-aid fix."

During today's visit, LPA toured the facility and interviewed facility staff.

According to house manager, the deck was newly refurbished. However, the ramp from the family room leading into the deck remained the same. In addition, house manager reported that the metal plates on each side of the ramp is to ensure an even surface from the family room into the deck.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20231102111838

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CRISTINA'S CARE HOME	FACILITY NUMBER: 415601076
	VISIT DATE: 11/08/2023

NARRATIVE

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During today's visit, LPA observed multiple nails were protruding from the wooden floor slabs and some wooden slabs were cracked. These observations were acknowledged by the house manager.

LPA observed the ramp from the family room leading to the deck to be sturdy and the mental plate at the end of the ramp created an even surface for residents who are in wheelchairs. According to the house manager, staff did not have any problems with wheeling residents around from the family room into the deck.

LPA interviewed the administrator over the phone who stated that the facility has contacted a contractor to come to the facility for the nails and the slabs in the deck, however, the administrator was not able to provide any proof of the repair.

Based on observations, and interviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Report was discussed with the house manager. A copy is provided and Appeal Rights provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20231102111838

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CRISTINA'S CARE HOME	FACILITY NUMBER: 415601076
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/08/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/09/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation..(a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by several nails protruding from the wooden floor slabs and a few cracked wooden	1 2 3 4 5 6 7	The administrator/licensee will provide a plan for the repair and on the plan, it shall include the date of repair to be completed and in the meantime, what is the facility's approach to ensure safety.
	8 9 10 11 12 13 14	slabs which poses an immediately health risk for residents in care.	8 9 10 11 12 13 14	The administrator/licensee will provide a copy of the plan and a photo(s)of the temporary fix to CCL by 11/9/2023.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

LIC9099 (FAS) - (06/04)

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