<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601077
Report Date: 05/21/2024
Date Signed: 05/21/2024 04:56:16 PM


Document Has Been Signed on 05/21/2024 04:56 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
SF COASTAL AC/SC, 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:
05/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Caregiver, Angelito SotingcoTIME COMPLETED:
12:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On May 21, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with caregiver, Angelito Sotingco and explained the purpose of the visit. The administrator, Oscar Madrigal arrived shortly thereafter and assisted with the rest of the inspection.

LPA toured the facility inside out and inspected the living room, dining area, kitchen, bedrooms, bathrooms, and backyard. The indoor and outdoor passageways were free of obstruction. The facility has 5 resident rooms (1 shared and 4 privates ) and 1 staff room. Furniture and furnishings were observed to be sufficient. Food supplies were sufficient of 2- days perishables and 7- days of non-perishables. Toilet, hand washing and bathing areas were observed clean and in operating condition. Showers were observed equipped with non-skid mats and grab bars. Facility exits are equipped with audible alarms. Comfortable temperature is maintained and lighting is sufficient for comfort
Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.

Central storage for medications, sharps and chemicals were observed to be locked and inaccessible to residents in care.

Hot water temperature in the kitchen and bathroom were measured at 108-119 degrees Fahrenheit. Fire extinguishers were checked and last inspected on 9/25/23.

A review of (5) resident files was conducted and noted on the LIC 858.
A review of (2) staff files was conducted and noted on the LIC 859.

The following documents were requested submitted to CCL by 5/23/24:
- Control of Property, LIC 500, and Liability Insurance.

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. .

This report is reviewed and discussed with administrator. A copy of this report and the appeal rights were provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024
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 2


Document Has Been Signed on 05/21/2024 04:56 PM - 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: CRISTINA'S CARE HOME
FACILITY NUMBER: 415601077

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)


This requirement is not met as evidenced by: LPA observed 2 residents have a half bedrail without a physician's order.
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 2 residents have a half bedrail without a physician's order.
which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2024
Plan of Correction
1
2
3
4
The administrator will submit a plan to ensure compliance and will provide a copy of the plan and a copy of the physician's order for the device to CCL by 5/29/2024.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2