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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202158
Report Date: 02/20/2025
Date Signed: 02/20/2025 04:48:26 PM

Document Has Been Signed on 02/20/2025 04:48 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/
DIRECTOR:
KIROS WOLDEGIORGISFACILITY TYPE:
735
ADDRESS:1320 RIDGEWOOD DRIVETELEPHONE:
(408) 202-2157
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY: 6CENSUS: 6DATE:
02/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Licensee/Administrator, Kiros WoldegiorgisTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA Rai met with Licensee/Administrator, Kiros Woldegiorgis and stated the purpose of today's visit. LPA Rai observed 3 staff 6 residents at the facility. The facility is vendorized by San Andreas Regional Center and is a level 4I 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 2 sheds in the backyard which was locked and used for storage and not 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 facility to include 3 resident rooms, living room, dining room, kitchen and garage. 3 Out of 3 resident bedrooms had available bedding, drawers, and functioning lights.  The facility bathroom had available soap, paper towels, and trash cans with lids. The hot water temperature in the bathroom and kitchen sink were measured at 120 degrees F. During the visit, Licensee/Administrator lowered the temperature of the hot water as a precaution.
Fire extinguisher was observed and inspected in 11/7/2024. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drills were conducted on 1/22/2025 & 2/6/2025.  LPA Rai observed a complete first aid kit at the facility. LPA Rai reviewed facility records for 2 staff and 2 residents. LPA Rai reviewed resident medications and central stored medication records.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensee/Administrator, Kiros Woldegiorgis and a copy of the report was provided. LIC 858 and LIC 859 were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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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