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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202158
Report Date: 01/08/2025
Date Signed: 01/08/2025 03:53:59 PM

Document Has Been Signed on 01/08/2025 03:53 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/
DIRECTOR:		KIROS WOLDEGIORGISFACILITY TYPE:
735
ADDRESS:1320 RIDGEWOOD DRIVETELEPHONE:
(408) 202-2157
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY: 6CENSUS: 6DATE:
01/08/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Designated Administrator/ House Manager (HM) Filimon ZewdeTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analysts (LPAs) Simi Rai and Marcela Yanez conducted an unannounced case management visit follow up on the Type A deficiencies cited on 12/27/2024. LPAs met with Designated Administrator/ House Manager (HM) Filimon Zewde and stated the purpose of today's visit. LPAs observed 6 resident and 3 staff are present at the facility.

LPAs reviewed the Plan of Correction submitted on 12/28/2024. HM stated the staff training is scheduled for Saturday, January 11th 2025 and will submit copy of the training and training log to LPA Rai.

LPAs reviewed LIC 500 Personnel Report 01/01/2025, there are three staff scheduled for today's shift.

During visit, LPAs provided letter of the Deficiency Citations cleared.

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

This report was reviewed with Designated Administrator/ House Manager (HM) Filimon Zewde and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
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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