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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801863
Report Date: 12/04/2023
Date Signed: 12/04/2023 07:35:59 PM

Document Has Been Signed on 12/04/2023 07:35 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
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: 4DATE:
12/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Cristina NoblejasTIME COMPLETED:
03:23 PM
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Licensing Program Analyst (LPA) A. Canela arrived at this facility unannounced, to conduct an Annual Required 1 year inspection and met with house manager, Estella Constantino; Christina Noblejas arrived a few minutes later. There are currently 5 clients living in the facility and they receive services from North Bay Regional Center. Facility is licensed for up to 6 Clients, of which 4 can be non-ambulatory and 2 will need to be ambulatory. No approval for bedridden residents. Facility has awake staff as there are no bedrooms for staff to sleep in.
Facility was found to be at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be charged and inspected 5/11/2023. Toxins are stored and not accessible. Facility has PPE supplies. Client medications are secured and locked. Facility has a 30-day supply of medication. LPA consulted with facility and provided information for requesting all non-ambulatory clients. LPA also consulted with facility regarding the push door that is getting a little stuck and will need to be serviced. LPA also reminded facility room #1's bathroom can only be used by the clients in room #1.
Due to technical difficulties with the Care Tool, LPA will return to facility to complete inspection,

Licensee/Administrator to submit updates of the below documents to LPA by 1/3/2024 and LPA will review and update file.
· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report-
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
Infection Control Plan of Operation (If changes)
Copy of Administrator Certificate

No citations issued during todays inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2023
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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