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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801863
Report Date: 10/21/2021
Date Signed: 10/22/2021 09:38:18 AM

Document Has Been Signed on 10/22/2021 09:38 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
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: 6DATE:
10/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Estella ConstantinoTIME COMPLETED:
03:32 PM
NARRATIVE
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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 was not available during the visit. There are currently 6 clients living in the facility and they receive services from North Bay Regional Center. LPA arrived at the facility and observed a cabinet at end of hall way by the front area with hand sanitizer and PPE supplies, staff took LPAs temperature but no Covid questions were asked. Facility was found to be at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be charged and inspected within the last 12 months. 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. Medications are secure and not accessible to clients. Facility has a 30-day supply of medication. Clients do not typically wear masks inside the facility but have them available. Staff were observed not wearing a mask during this visit, LPA requested all 3 staff to please put a mask on and reminded them to follow their Covid-19 mitigation plan and that masks must be worn by staff at all times they are inside this facility regardless of vaccination status. LPA reminded facility of requirement to maintain track of all visitors vaccination status.
LPA observed the facility is doing major bathroom remodeling in client C1's bedroom. Facility was reminded to inform CCL of any major repairs to this facility prior to construction. The bathroom was observed with flooring removed, wood appeared to be rotted, LPA was able to smell the water damaged wood, smell of mold and requested facility to provide information regarding work being done and date of completion. LPA also requested plan to ensure the safety of clients who occupy the bedroom. LPA also consulted in regards to facility ensuring all knifes are inaccessible.

The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights and this report will be emailed to facility due to printer problems.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2021
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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Document Has Been Signed on 10/22/2021 09:38 AM - It Cannot Be Edited


Created By: Araceli Canela On 10/21/2021 at 02:46 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: CRISMA CARE FACILITY
FACILITY NUMBER: 486801863

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/22/2021
Section Cited
CCR
80087(a)

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80087(a) Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
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Facility to send in written plan of how they will ensure client C1 and the rest of the clients do not have access to the smell of mold/wrotten wood from the bathroom.
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This requirement was not met, during todays inspection LPA observed bathroom in Client C1s room had a very strong odor of rotten/water damaged wood/mold that C1 is breathing. LPA was unable to handle the smell. LPA also observed piles of wrotten wood in side back yard along with furniture items, hoyer lift, chairs that need to be removed. This is an immediate risk to the health and safety of clients in care.
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POC due date 10/22/2021 to LPA Araceli Canela
Type B
10/25/2021
Section Cited
CCR80086(a)

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80086(a) Alterations to Existing Building or New Facilities. (a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.
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Facility to send in notification to LPA Canela regarding the work being done in the bathroom, plan of completion. In addition, statement facility understands regulation and requirment to notify CCL
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This requirement was not met as evidenced by ; LPA and CCL was not notified a major bathroom remodeling was being done.
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POC due date 10/25/2021 to LPA Araceli Canela
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: 10/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2021


LIC809 (FAS) - (06/04)
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