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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601077
Report Date: 07/07/2021
Date Signed: 07/07/2021 11:11:24 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:CRISTINA'S CARE HOMEFACILITY NUMBER:
415601077
ADMINISTRATOR:MADRIGAL, OSCARFACILITY TYPE:
740
ADDRESS:1580 CRESTWOOD DRIVETELEPHONE:
(650) 737-0803
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: 6DATE:
07/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Oscar MadrigalTIME COMPLETED:
11:15 AM
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On 07/07/2021, Licensing Program Analyst (LPA) Jaime Vado toured facility's building and grounds. LPA met with caregiver Josephine Quiba and explained purpose of today's inspection. Administrator Oscar Madrigal arrived at facility at 1040 and met with LPA. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is observed as in place. Medications, toxins and sharps are stored appropriately and inaccessible to clients. Facility ambient temperature is comfortable and lighting is sufficient for residents and staff safety. Toilet and bathing facilities are equipped with grab bars and non-skid flooring material. Liquid soap is available. First-aid kit is inspected and complete. A disaster and mass casualty plan is present but needs to be updated. There are 5 residents present and 2 staff and administrator. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Staff files reviewed and are current with first aid cards and training materials. New staff is present on this day is associated and being trained. COVID mitigation plan (LIC808) is not present in the facility but has been submitted to CCLD for review. LPA is requesting the LIC808 to be received by 07/09/2021.

The following updated forms are requested to be submitted to CCLD by 07/16/2021:

• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 610E Emergency Disaster Plan
• Articles of incorporation
• Neighborhood complaint procedures

No deficiencies cited. Report is reviewed with administrator.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
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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