486801863-12-20-2022-21-AS-ACAA-CMB32Z-20221220165246

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486801863
Report Date: 12/20/2022
Date Signed: 12/20/2022 04:56:53 PM

Document Has Been Signed on 12/20/2022 04:56 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 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:	12/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Cristina Noblejas, Administrator/Licensee		TIME COMPLETED:	02:26 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 conduct an Annual Required 1 year inspection. This inspection will focus on the Infection Control procedures and practices of this facility. LPA 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. LPA arrived at the facility and observed a cabinet at the front porch with a sign -in book, and hand sanitizer. LPA recommended, the thermometer be placed closer to the entrance door, so that staff do not need to go back to the kitchen where the thermometer is kept. Facility was found to be at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be charged and inspected 5/2022. Toxins are stored and not accessible. Facility has submitted and received approval for a Covid Mitigation plan. Covid-19 Posters are in place at the entrance and throughout the facility. Facility has PPE supplies. Staff wear mouth covering while in the facility. Facility takes daily temperatures of staff and clients. Client medications are secured and locked. Facility has a 30-day supply of medication. Clients do not typically wear masks inside the facility but have them available. LPA consulted with facility regarding the left yard gate that needs to be adjusted so it latches easily. LPA also reminded facility room #1's bathroom can only be used by the clients in room #1. Continue report see LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

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: 12/20/2022

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LPA requested the following updated records to be submitted to Community Care Licensing by 1/15/2023

· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 402 Surety Bond, if applicable
· LIC 610D Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
· Copy of current, updated facility/yard sketch
· Copy Administrator Certificate

Exit interview conducted with Christina Noblejas, Licensee/Administrator.

No deficiencies cited during this inspection

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC809 (FAS) - (06/04)

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