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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202158
Report Date: 02/13/2024
Date Signed: 02/13/2024 01:48:21 PM

Document Has Been Signed on 02/13/2024 01:48 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:KRISTINE MANOR II, LLCFACILITY NUMBER:
435202158
ADMINISTRATOR:KIROS WOLDEGIORGISFACILITY TYPE:
735
ADDRESS:1320 RIDGEWOOD DRIVETELEPHONE:
(408) 202-2157
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY: 6CENSUS: 5DATE:
02/13/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Administrator, Kiros WoldegiorgisTIME COMPLETED:
01:50 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
Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit to follow up on the Type A deficiencies cited on 2/7/2024. LPA Rai met with Administrator, Kiros Woldegiorgis and stated the purpose of today's visit. LPA Rai observed 2 staff, including Administrator and 4 residents present at the facility. 1 resident is attending day program.

During visit, LPA Rai toured the 2 resident rooms and observed the window screens in good repair.

LPA toured the garage and observed the space with a sofa and dining table. No signs of the space being used as habitual space.

LPA observed the staff room across the living room. The staff room was locked. ADM unlocked the staff room and LPA observed two beds with personal items.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Administrator, Kiros Woldegiorgis and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2024
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 1