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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202174
Report Date: 02/28/2023
Date Signed: 02/28/2023 02:35:23 PM

Document Has Been Signed on 02/28/2023 02:35 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 I, LLCFACILITY NUMBER:
435202174
ADMINISTRATOR:VICTORIA ALEJANDROFACILITY TYPE:
735
ADDRESS:5264 MERIDIAN AVE.TELEPHONE:
(408) 202-2157
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY: 6CENSUS: 6DATE:
02/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:48 PM
MET WITH:Care Staff, Sisay AmbayeTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced annual inspection focusing on infection control. LPA met with Care Staff Sisay Ambaye. LPA Rai spoke with Administrator Victoria Alejandro over the phone and informed her of the visit.

During visit, LPA Rai toured the facility to include the family room, 3 resident rooms, 2 bathrooms, kitchen, laundry area, dining area, garage and exterior. All fire exit routes are free and clear of obstruction. Toxins and sharp objects were secured.

Facility observed to have a designated central entry point to include a sign-in sheet and temperature check. Facility clean and disinfect twice daily and as often as needed. Bathrooms supplied with hygiene products and hand washing sign. Trash can with lid observed. LPA observed a sufficient amount of Personal Protective Equipment (PPE).

The following posters observed to include wash your hands and symptoms of COVID-19.

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with Care Staff Sisay Ambaye and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2023
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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