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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202158
Report Date: 12/27/2024
Date Signed: 12/27/2024 04:43:37 PM

Document Has Been Signed on 12/27/2024 04:43 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:
12/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Designated Administrator/ House Manager (HM) Filimon ZewdeTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai arrived unannounced to conduct a case management visit to follow up on Incident Report for 11/25/2024 where resident R6 left the facility without the knowledge of the staff. LPA Rai met with Designated Administrator/ House Manager (HM) Filimon Zewde and stated the purpose of today's visit.

On 11/25/2024 at 6:00pm, R6 returned the facility after visiting family. At around 10:00pm, staff observed R6 going to the room. At approximately 1:30am, staff did their routine rounds of the facility and observed R6 was not at the facility. Facility staff drove around the neighborhood and did not find R6. At approximately 1:50am, R6 returned to the facility by himself/herself. R6 notified staff that he/she went to the store to buy soda and left the facility through the back door through the back yard exit.

During today's visit, LPA Rai interviewed Designated Administrator/ House Manager (HM) Filimon Zewde regarding the Incident Report. HM stated they have placed door alarms on the exit doors leading out of the facility to the main street. HM stated R6's elopement behaviors are initiated when R6 returns from visiting family. HM stated they routinely will take R6 to the store when R6 returns back to the facility after visiting family to ensure R6 purchases items and does not display the elopement behavior to go out to purchase the items himself/herself. HM stated they will collaborate with San Andreas Regional Center (SARC) to provide R6 1:1 staff supervision when R6 returns back to the facility after visiting family. HM stated there is 1 awake staff at night during the hours of 10pm to 6am.

Based on review of LIC 500 dated 12/1/2024, LPA Rai reviewed 1 staff is scheduled to work 8pm to 8am Monday through Friday and 1 staff is scheduled to work 8pm to 8am Saturday and Sunday.

Continuation on LIC 809-C, Page 1 of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2024
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 12/27/2024 04:43 PM - It Cannot Be Edited


Created By: Simranjit Rai On 12/27/2024 at 03:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 12/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/28/2024
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.
This requirement is not met as evidenced by:
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Licensee/Administrator to submit a written plan of action understanding regulation and will ensure staff are present at the facility to provide care and supervision to meet the resident's needs by POC due date. Licensee/Administrator was not present at the facility during today's visit.
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Based on observation, Licensee did provide necessary supervision to residents wherein 1 staff was present to be 1:1 care staff to resident R1 & supervise 4 other residents at the same time which poses/posed an immediate Health, Safety, or Personal Rights
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(cont') risk to persons in care.
Type A
12/28/2024
Section Cited
CCR80065(a)

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80065 Personnel Requirements (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
This requirement is not met as evidenced by:
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Licensee/Administrator to submit a written plan of action understanding regulation and will provide in-service training to staff to ensure resident's needs are met which include supervision by POC due date. Licensee/Administrator was not present at the facility during today's visit.
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Based on observation, Licensee did not ensure staff were compentent to provide supervision to residents in care which poses/posed an immediate Health, Safety, or Personal Rights risks to persons in care.
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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:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2024


LIC809 (FAS) - (06/04)
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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: 12/27/2024
NARRATIVE
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Based on review of R6's Individual Program Plan (IPP) dated 4/18/2024, there were times that R6 went AWOL. R6 is known to go to grandmother's house. R6 needs to be safely supervised by a responsible adult at all times to ensure daily needs are met. R6 requires adult supervision to ensure health and safety.

Based on review of R6's Appraisal/Needs and Services dated 4/20/2024, R6 always needs to be supervised due AWOL behavior. Based on review of R6's Appraisal/Needs and Services dated 10/29/2024, R6 exhibits suddenly AWOL behavior and R6 will be provided constant supervision to avoid AWOL behavior. Staff will ensure to avoid situations that will trigger R6. R6 will be encouraged to socialize with roommate and make other friends.

Upon arrival to the facility during today's visit, LPA Rai was walking to the facility when observed 1 staff (S1) outside of the facility, directly across the street, following resident (R1) who was displaying elopement behavior. LPA Rai observed S1 redirecting resident back to the facility but was unsuccessful. LPA Rai approached the front door and observed resident (R2) waiting by the front porch. LPA observed S1 following R1 away from the facility and R2 followed both of them across the street and out of LPA's sight. LPA Rai approached the front door and observed 3 residents (R3-R5) in the living room unsupervised and there were 0 staff present at the facility. LPA Rai observed HM arrive at the facility shortly and entered the facility.

HM stated there were three staff schedule at the facility which included S1, S2 and himself. HM stated S2 was on break and not at the facility. HM stated R1 need 1:1 supervision and S1 is R1's designated 1:1 staff. HM stated he was out of the facility running errands during the time of the incident and there were 0 staff present at the facility.

LPA Rai reviewed LIC 500 and observed HM and S2 on scheduled shift for Friday from 6am to 8pm and S1 is off shift on Fridays.

LPA Rai suggested for HM to follow staff schedule and ensure there is staff present at the facility to supervise the residents when HM needs to step out of the facility.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 12/27/2024
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Page 3 of 3.
Deficiencies are being cited per California Code of Regulations, Title 22. See LIC 809-D.

A civil penalty is being assessed for the amount of $500 for the absence of supervision at the facility. Please see LIC421IM.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Designated Administrator/ House Manager (HM) Filimon Zewde and a copy of the report and Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024
LIC809 (FAS) - (06/04)
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