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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601078
Report Date: 02/21/2024
Date Signed: 02/21/2024 12:15:30 PM


Document Has Been Signed on 02/21/2024 12:15 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:
415601078
ADMINISTRATOR:MADRIGAL, OSCARFACILITY TYPE:
740
ADDRESS:2735 FLEETWOOD DRIVETELEPHONE:
(650) 952-5370
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: 6DATE:
02/21/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Caregiver, Wilfredo MonoyTIME COMPLETED:
12:30 PM
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On February 21, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management Health Checks visit due to an incident that was reported by the facility on February 14, 2024. LPA met with caregiver, Wilfredo Monoy and explained the purpose of the visit. The administrator, Oscar Madrigal arrived shortly thereafter and assisted with the rest of the visit.

On February 14, 2024, facility reported that resident #1(R1) had a change of health condition and was transferred to the hospital. On the day of R1's discharge, the facility was notified by the hospital that R1 alleged sexual abused by staff #1 (S1).

During today's visit, LPA toured the facility with caregiver observed facility to be cleaned and tidy and residents to be calm and comfortable. LPA spoke to residents, staff and administrator.

According to the administrator, when the facility was notified of the incident, the facility started to investigate and implemented interventions to ensure the safety of the resident.

According to the residents, they are doing well and staff members are providing the care that they need.

The administrator also reported that R1 has returned to the facility with no further concerns.

No deficiency cited today.

This report is reviewed and discussed with the administrator; A copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024
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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