486801863-12-28-2023-21-AS-ACAA-CYXR29-20231228113759

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486801863
Report Date: 12/27/2023
Date Signed: 12/28/2023 11:38:38 AM

Document Has Been Signed on 12/28/2023 11:38 AM - 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 FACILITY		FACILITY NUMBER:	486801863
ADMINISTRATOR:	NOBLEJAS, CRISTINA		FACILITY TYPE:	735
ADDRESS:	100 ARAGON STREET		TELEPHONE:	(707) 644-8828
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY: 6		CENSUS: 5	DATE:	12/27/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	12:06 PM
MET WITH:	Cristina Noblejas		TIME COMPLETED:	03:22 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) A. Canela arrived at this facility unannounced, to continue the Annual Required 1 year inspection from 12/4/2023 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. During previous inspection, LPA went over bedroom # 2 that is only approved for Ambulatory clients. Licensee expressed she wanted to check with the fire department to see if that room could be used by non-ambulatory clients. The Vallejo fire inspector would be doing a visit to go over fire alarm corrections needed and she would address with them. LPA provided the forms needed to be submitted to the department, so that LPA could request a new fire clearance. LPA spoke with fire inspector MZ who expressed the facility has fire sprinklers and room #2 could be used for non-ambulatory but the room could only house 1 client. This would require the facility to change paperwork and decrease capacity from 6 to five clients. Facility decided not to request the change and would maintain their current licensed capacity of 6, of which 4 can be non-ambulatory and 2 will need to be ambulatory in room#2. LPA reached out to the fire inspector and explained the facility would be withdrawing their request and maintain their current status, there for the fire inspector would not receive a formal written request for a new fire clearance. Facility was found to be at a comfortable temperature and all clients were out of the facility at day programs. 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 went over the push door that was previously getting a little stuck and the facility has serviced the door and is working properly. Continue report see LIC809-C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 FACILITY	FACILITY NUMBER: 486801863
	VISIT DATE: 12/27/2023

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Continued report from LIC809
LPA spoke with licensee by phone and went over the area/room between room 1 and 3 with the push door needing to be with less items in the room, so the area can be used properly to keep the clients wheelchairs and walkers. This sitting area has a futon, that facility states is not being used, a tall dresser and a wooden closet type cabinet that is being used by staff S1 to keep their personal belongings, a file cabinet and a wooden shelf for files. LPA explained the facility has to be used and catered for the clients use and well being. LPA explained they will need to remove the futon or some items so that the area is used to keep the clients wheelchair/walker and that there is enough room for the clients safety and that no doors or passage ways are BLOCKED. Licensee agreed to remove the futon or any items to ensure there is room for clients devices. LPA also reminded facility room #1's bathroom can only be used by the clients in room #1.

LPA went over client and staff files.LPA requested C1 gets a new physician report as the current one in file is not dated. LPA went over documents needed for facility to request an age exception for one of the clients. At this time there are 2 clients under age and 3 clients over the age and facility requires an approved age exception from Community Care Licensing. Staff files have proof of CPr/1st aid and staff S1 expires 12/29/2023. S1 expressed they recently completed training and are waiting for their current card. LPA requested facility to provide clients C1 with current physician report, report in file had no date and needs correction.

LPA went over requirements to decrease capacity with licensee.

Licensee/Administrator to submit updates of the below documents to LPA by 1/10/2024 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: 12/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC809 (FAS) - (06/04)

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