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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601078
Report Date: 05/08/2024
Date Signed: 05/08/2024 05:40:36 PM


Document Has Been Signed on 05/08/2024 05:40 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: 5DATE:
05/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Caregiver, Maria RazonTIME COMPLETED:
12:00 PM
NARRATIVE
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On May 8, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with caregiver, Maria Razon 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 4 resident rooms (two shared and 2 private room) 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 unlocked and accessible to residents in care.

Hot water temperature in the kitchen and bathroom were measured at 105-112 degrees Fahrenheit. Fire extinguishers were checked and last inspected on 4/2/2024.

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 5/9/24:
- 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: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
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 4


Document Has Been Signed on 05/08/2024 05:40 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: 415601078

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(12)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 2 out of 2 facility staff did not have TB screening documentation in their personnel file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2024
Plan of Correction
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The administrator/licensee will develop a plan to ensure this does not happen again and provide a copy of the signed and dated plan to CCL by 5/9/2024 and a copy of the TB screening documentation for these facility staff.
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the facility was not able to provide proof that emergency drills were conducted which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2024
Plan of Correction
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The administrator/licensee will develop a plan to ensure drills are conducted accordingly and will provide a copy of the signed and dated plan to CCL by 5/9/2024.
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: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 05/08/2024 05:40 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: 415601078

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed sharps, chemicals and medications are not locked and accessible to resident in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2024
Plan of Correction
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The administrator/licensee will develop a plan to ensure this does not happen again and will provide in-services to staff. The administrator/licensee will provide a copy of the signed and dated plan and staff in-service record to CCL by 5/9/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 05/08/2024 05:40 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: 415601078

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(j)
Criminal Record Clearance
(j) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of employees in the individual's personnel file as required in Section 87412, Personnel Records.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 1 out of 2 staff did not have criminal record clearances in the personnel file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2024
Plan of Correction
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The administrator/licensee will develop a plan to ensure this does not happen again and provide a copy of the signed and dated plan to CCL by 5/13/2024. In addition, the administrator will provide a copy of the document to CCL by 5/13/2024.
Type B
Section Cited
CCR
87411(c)(6)
Personnel Requirements - General
(6) The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training. Each item of documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 2 out of 2 staff did not have documentation in the personnel files to proof that staff training was completed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2024
Plan of Correction
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The administrator/licensee will develop a plan to ensure this does not happen again and provide a copy of the signed and dated plan to CCL by 5/13/2024. In addition, the administrator will provide a copy of the in-service training records to CCL by 5/13/2024.
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: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4