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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801863
Report Date: 11/09/2021
Date Signed: 01/28/2022 01:25:24 PM

Document Has Been Signed on 01/28/2022 01:25 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, 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:
11/09/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:06 PM
MET WITH:Christina NoblejasTIME COMPLETED:
05:22 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 facilities plan of correction regarding bathroom remodel in client C1's bedroom. The bathroom was observed to have the flooring completed and the room does not have the smell of mold or mildew. Licensee explained the bathroom should be completed and the end of this month.

Upon arrival to the facility , staff were once again not wearing any face/mouth coverings. LPA previously reminded the facility, mask should be worn regardless of vaccination status. LPA requested facility to take LPAs temperature and staff never asked LPA any Covid-19 questions or requested LPA to sign in. LPA noticed staff S1 attempting to lock medication cabinet that had been left unopen. On previous visit, the medication closet was open and staff stated they had just open it and were about to close it. During today's visit the same excuse was given to LPA.

LPA also enquired regarding paperwork facility stated they had, for a pest exterminator service. On LPAs previous visit, LPAs foot was ran over by a large rat. Today, LPA inspected kitchen cabinets and no rat/mouse dropping were observed. LPA requested facility to send paperwork of terminix to LPA for review.

LPA spoke with licensee regarding client C3 who's bed appeared not to be used as it had several piles of folded clothing. Client C4 explained, they have been sleeping in that room by themselves and C3 does not sleep there. LPA was informed C3 does not want to sleep on their bed and sleeps in the living room. Facility explained, they have never notified CCL and may have told NBRC but is not sure. LPA explained this is a personal rights violation.
Continue report see LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2021
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 FACILITY
FACILITY NUMBER: 486801863
VISIT DATE: 11/09/2021
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Facility to review sleeping accomodations with C3's physician, submit doctors note for C3 to be able to sleep on a chair. C3 may only sleep in their room and should not sleep in living room. LPA will review and address issue after review.

LPA asked licensee if the facility had a staff to client ratio with North Bay Regional Center. LPA was unable to review all files, licensee and staff explained they were 2:1 but then stated 3:1. LPA explained I would confirm with NBRC and address issue of how many clients per staff are required. Facility explained they had 3 staff but one was not there yet or at lunch break.
LPA explained at this time and on a previous visit, facility had 2 staff working with 6 clients and an additional staff arrived later.

LPA reviewed facility sketch and is unable to determine which rooms were approved by the fire department as non ambulatory and ambulatory.
LPA asked facility for their sketch of 2015 and administrator explained the file was not at this facility. LPA will review and an additional fire clearance may be requested.

LPA requested copies of all clients Physician report LIC602.

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: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/28/2022 01:25 PM - It Cannot Be Edited


Created By: Araceli Canela On 11/09/2021 at 04:59 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: 11/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/16/2021
Section Cited
CCR
80075(k)(1)(3)

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80075(k)(1) Health related services- The following requirements shall apply to medications which shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication
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Facility to send in written plan along with proof os staff training.
LPA requested Med closet to be locked during visit.
POC due date 11/16/2021
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This requirement wa not met as evidenced by: LPA observed the hall closet medication cabinet not locked, S1 was observed trying to lock ited staff during visit.
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Type B
12/09/2021
Section Cited
CCR87405(d)(1)

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87405(d)(1) Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.(1)Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement was not met. This requirement is not met as evidenced by:
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Facility to send in written plan, that all staff have knowledge of the requirements of Covid-19 precautions from CCL and CDC.
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Based on observation, the licensee did not comply with the section cited above, facility staff failed to ensure staff S1 wears face mask coverings, while providing care to residents which poses/posed a potential health, safety or personal rights risk to persons in care.
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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: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2021


LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 01/28/2022 01:25 PM - It Cannot Be Edited


Created By: Araceli Canela On 11/09/2021 at 05:02 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: 11/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2021
Section Cited
CCR
85087(a)(3)

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85087 Buildings and Ground(a) In addition to Section 80087, bedrooms must meet, at a minimum, the following requirements:.(3) No room commonly used for other purposes shall be used as a bedroom for any person.
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Facility to send in written plan regarding C3s sleeping accommodations and that they understand regulation
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This requirement was not met as evidenced by: During today's visit LPA received information client C3 does not sleep in her room and has been sleeping in the living room in a chair/recliner. This is an immediate risk to the health and safety of residents in care,
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POC due date 11/18/21 to allow a safe plan for C3

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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: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2021


LIC809 (FAS) - (06/04)
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