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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801863
Report Date: 02/25/2022
Date Signed: 03/01/2022 03:07:35 PM

Document Has Been Signed on 03/01/2022 03:07 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CRISMA CARE FACILITYFACILITY NUMBER:
486801863
ADMINISTRATOR:NOBLEJAS, CRISTINAFACILITY TYPE:
735
ADDRESS:100 ARAGON STREETTELEPHONE:
(707) 644-8828
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 5DATE:
02/25/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Christina NoblejasTIME COMPLETED:
05:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) A. Canela arrived at this facility unannounced, to conduct a case management inspection and met with house manager, Estella Constantino; Christina Noblejas was asked to come in to the facility and meet with LPA. This Case management inspection is to go over a Death report that was called in to CCL for client C1 and to issue citations for the facility failing to report incidents.
Per conversation with facility staff(S1), Client C1 was first observed to have swelling/red in right foot on December 7th 2021 during C1's annual physical. C1 was sent to get an MRI to rule out blood clot and antibiotics were prescribed. On January 24th, 2022 C1's Physician(podiatry) prescribed additional antibiotics and C1 was to have a follow up with Podiatry. Staff S1 states C1 had her first doze of antibiotic on the evening of 1/24 and on the morning of 1/25/22, C1 was observed to be very quiet and S1 called 911. C1 was admitted to Sutter Solano Hospital in the intensive care unit. C1 remained at the hospital until C1's passing on February 12, 2022. LPA requested hospital records regarding C1, from facility and a copy of the Death Certificate.
In review of records, LPA discovered C1 had 2 seizures in the month of December, 2021 and facility failed to report incident to C1's physician and to Community Care Licensing (CCL) as required. Staff S1 disclosed C1 had not had any seizures for a couple of years. It was also disclosed to LPA, of a staff testing positive for Covid and Administrator failed to report the Covid case to CCL. LPA went over reporting requirements and Administrator qualifications and duties. In a previous phone conversation with Administrator, Christina Noblejas, it was expressed she did not understand why she cannot run her facility from her private home and feels she does not have to be present at the facility. LPA went over Administrators requirements and time to be present at the facility to ensure compliance. See 809-D for deficiencies observed and cited.
Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Appeal rights and report will be emailed today to facility, due to technical issues.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2022
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 2
Document Has Been Signed on 03/01/2022 03:07 PM - It Cannot Be Edited


Created By: Araceli Canela On 02/25/2022 at 03:17 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CRISMA CARE FACILITY
FACILITY NUMBER: 486801863

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/11/2022
Section Cited
CCR
85064(e)

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85064(e) Adminstrator Qualifications and Duties- (e) The administrator shall be on the premises the number of hours necessary to manage and administer the facility in compliance with applicable law and regulation.
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Facility to send in written plan of correction on facilities plan to ensure an Administrator is present a number of hours necessary to manage and administer the facility.
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This requirement was not met, as evidenced by: LPA has made several visits, called the facility regarding facility concerns and Administrator has not been there. Administrator disclosed to LPA, she lives near by and those not need to be present at her facility on regular basis. Facility has not been in compliance & administrator has failed to manage the facility properly. This is a Potential risk to the health & safety of clients in care.
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POC due date 3/9/2022 attention: LPA Araceli Canela
Type B
03/09/2022
Section Cited
CCR80061(b)

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80061(b) Reporting Requirements (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.
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Facility to send in written plan of correction on facilities plan to ensure incident reports are called and submitted within the required time. Staff training and documentation
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This requirement was not met, as evidenced by: In review of records It was noted client C1 had 2 seisures in december not reported, Covid Positive case for staff, was not reported. This is a Potential risk to the health & safety of clients in care.
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Facility to submit incident reports for C1s Seizures.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Araceli Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022


LIC809 (FAS) - (06/04)
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