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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202174
Report Date: 02/13/2024
Date Signed: 02/13/2024 12:12:41 PM

Document Has Been Signed on 02/13/2024 12:12 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:
02/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Licensee, Kiros WoldegiorgisTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA met with Administrator (ADM) Kiros Woldegiorgis and stated the purpose of today's visit. LPA Rai observed 2 staff and 2 residents at the facility with 4 residents attending day program.

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 one 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.

The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 109.4 degrees F - 110.5 degrees F. LPA Rai observed 1 out of 2 bathrooms had the window screens in disrepair, wherein insects, dirt and debris would be able to enter the room. ADM stated the maintenance staff will come today and fix the screen. ADM will provide a photo of the repaired screen once completed. LPA Rai observed the hallway bathroom's lights wherein 2 out of the 4 lights were missing. Staff Sisay stated he was working on the bathroom lights and he was able to fix the lights during today's visit. Fire extinguisher was observed and inspected on 11/15/2023. Facility smoke detectors and carbon monoxide detectors were in working condition. LPA Rai reviewed facility records for 3 staff and 3 residents. LPA Rai reviewed resident medications and central stored medication records.

No deficiencies were cited per California Code of Regulations, Title 22. Technical Violation was given. This report was reviewed with Administrator (ADM) Kiros Woldegiorgis. A copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2024
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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