435202158-2-7-2024-26-AS-SRAI-D28RMA-20240207120825

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202158
Report Date: 02/07/2024
Date Signed: 02/07/2024 12:08:34 PM

Document Has Been Signed on 02/07/2024 12:08 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, LLC		FACILITY NUMBER:	435202158
ADMINISTRATOR:	KIROS WOLDEGIORGIS		FACILITY TYPE:	735
ADDRESS:	1320 RIDGEWOOD DRIVE		TELEPHONE:	(408) 202-2157
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95118
CAPACITY:	6	CENSUS: 5	DATE:	02/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator, Kiros Woldegiorgis		TIME COMPLETED:	12:15 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 Required 1 Year visit and met with Administrator (ADM) Kiros Woldegiorgis. LPA Rai observed 2 staff and 5 residents at the facility. During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai observed two storage sheds which were locked and not used as habitual space. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents. LPA Rai toured the resident bedrooms. 3 out of 3 resident bedrooms had available bedding, drawers, and functioning lights. LPA Rai observed 2 out of 3 resident bedrooms had the window screens in disrepair, wherein insects, dirt and debris would be able to enter the room. Administrator had two new window screens, but due to the weather conditions at the time, Administrator and staff were not able to repair the window screens. Administrator scheduled a professional to come into the facility this week to repair the window screens. LPA Rai toured the garage and observed three beds, one bed was located in the garage and two beds were located in a smaller room built inside the garage. ADM states the bed is for lounging for staff and the smaller room is a staff room used as habitual space by 2 staff (S1-S2). ADM stated he does not have a fire clearance for the staff room located in the garage. Based on facility sketch, the staff room located in the facility is being used as office space. Administrator will submit an updated facility sketch and move the staff back into the staff room. Continuation on LIC 809-C, Page 1 of 2.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

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 3

Document Has Been Signed on 02/07/2024 12:08 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: KRISTINE MANOR II, LLC	FACILITY NUMBER: 435202158
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

85087(a)(3)(A)

Building and Grounds

(3) No room commonly used for other purposes shall be used as a bedroom for any person. (A) Such rooms shall include but not be limited to halls, stairways, unfinished attics or basements, garages, storage areas, and sheds, or similar detached buildings. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the Administrator did not comply with the section cited above in staff room located in the garage was being used as bedroom for 2 staff members (S1-S2) and which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/08/2024
	Plan of Correction
1 2 3 4	Administrator stated the facility will remove the beds and the personal items and move them into the staff room. Admnistrator will use the space as an office. Administrator will submit written plan understanding regulation and plan of action by POC date.

Type A

Section Cited

CCR

80020(a)

80020 Fire Clearance (a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the facility sketch provided to the Department does not include the the staff room located in the garage which is being used as a habitual space which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
	POC Due Date: 02/08/2024
	Plan of Correction
1 2 3 4	Administrator will submit an updated LIC 999 Facility Sketch. Administrator will move staff back into the staff room and use the room in the garage as a office space. Administrator will submit a written plan understanding regulation and plan of action by POC date.

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: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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, LLC	FACILITY NUMBER: 435202158
	VISIT DATE: 02/07/2024

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
26
27
28
29
30
31
32

Page 2 of 2.

The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks was 105.1F. Fire extinguisher was observed and inspected on 11/15/2023. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drill was conducted on 09/30/2023.

LPA Rai reviewed facility records for 2 staff and 2 residents. LPA Rai reviewed resident medications and central stored medication records.

During visit, LPA obtained the following documents: LIC 500, Surety Bond Payment Receipt, LIC 610D, Lease Agreement and Administrator Certification. Administrator will fax the following documents by Friday 02/09/2024: LIC 309 and LIC 400.

Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. Technical Violation was given. This report was reviewed with Administrator (ADM) Kiros Woldegiorgis. A copy of the report and Appeal Rights were provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3