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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006686
Report Date: 04/28/2025
Date Signed: 04/28/2025 11:25:37 AM

Document Has Been Signed on 04/28/2025 11:25 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CRISTINA HOME CARE LLCFACILITY NUMBER:
306006686
ADMINISTRATOR/
DIRECTOR:		COMAN,CRISTINAFACILITY TYPE:
740
ADDRESS:5921 AMBERDALE DRTELEPHONE:
(714) 463-4489
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 6CENSUS: 0DATE:
04/28/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Applicant Cristina ComanTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On April 28, 2025, at 8:00 AM, Licensing Program Analyst (LPA) Edward Kim conducted an announced visit to the facility to conduct the pre-licensing inspection. LPA Kim met with Applicant Cristina Coman and toured the facility.

An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to CCL on January 2, 2025. The facility is to have a capacity of six (6) residents, six (6) can be nonambulatory and has a hospice waiver for 2 residents. Facility phone number (714-463-4489). LPA Kim observed the following.

Structure:
The facility is a one-story house with an attached 2 car garage with three (3) resident bedrooms, two (2) bathrooms, dining area, a kitchen, and a living area. There are four (4) exits: one exit door in the dining area, one in the main entrance, one exit in the living area, and one exit in bedroom #3.

Air/Heating:
Central air/heating system installed with a central panel to control entire house located on the wall in the living area. Temperature was at 74 degrees Fahrenheit

Resident Bedrooms:
There are three (3) Resident Bedrooms: Bedroom #1, Bedroom #2, and Bedroom #3. The bedrooms are spacious and will easily accommodate the residents' belongings. Bedroom #3 is missing a door upon entering room from the hallway. Bedroom#1 has two hospital beds with full rails.
Evaluation Report Continues on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Edward Kim
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2025
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
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CRISTINA HOME CARE LLC
FACILITY NUMBER: 306006686
VISIT DATE: 04/28/2025
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Staff Bedrooms:
There are no staff bedrooms.

Bathrooms:
All bathrooms have a working toilet, wash basin, and shower. All bathrooms are clean. Shower mats were missing in all two bathrooms. Hot water was measured in all bathrooms and measured between 136.5 degrees Fahrenheit to 138.9 degrees Fahrenheit.

Linens & Hygiene Supplies:
Adequate supply of linen stored in a cabinet in the resident hallway next to bedroom #1 and bedroom #2..

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed and are all posted on the wall in the living area.

Food Service:
There is 7-day non-perishable food supply on hand in the kitchen cabinet next to the refrigerator and in the closet across from bathroom #1 in the hallway. The emergency food is stored in the closet across from bathroom #1 in the hallway. Emergency water and emergency supplies are stored in the garage.

Toxins:
All cleaning supplies and chemicals are kept in the garage and locked underneath the kitchen sink

Smoke Detectors/Carbon Monoxide Detectors:
Smoke detectors/carbon monoxide detectors are hardwired and tested operational. There are two fire extinguishers that are fully charged and were bought on December 7, 2024, and are mounted on the wall next to the resident hallway entrance and in bedroom #3.

Outdoor/Yard:
There are two outdoor shaded areas that covers the tables and chairs in the yard.

Evaluation Report Continues on LIC 809-C.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Edward Kim
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CRISTINA HOME CARE LLC
FACILITY NUMBER: 306006686
VISIT DATE: 04/28/2025
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Medications, First-Aid Kit & Book:
All medications are stored in medical cabinet, which is in the living area. The first aid kit is stored in the closet across bathroom #1. The first aid kit was missing the first aid manual.

Resident & Staff Files:
The Resident and Staff Records will be kept locked in filing cabinets in the living room.

Reading Material, Games, Equipment & Materials:
Art supplies and activity supplies are stored in the living room and in the closet across bathroom #1. There is a large screen TV in the living room. The facility has a tablet dedicated for residential use that has internet access capability and has video teleconferencing software.

Appliances:
There is one five (5) gas burner stove which lights unassisted, oven, microwave oven, a refrigerator in the kitchen, a refrigerator in the garage, dishwasher, washer, and dryer. All appliances are clean and operational.

Fire clearance:
Fire Clearance approved by Orange County Fire Authority on February 3, 2025.

Component III:
Component three will be discussed on the next visit.

During the pre-licensing inspection, LPA Kim observed the following items that must be corrected:
1) Bedroom #3 is missing a door upon entering bedroom #3, 2) Outdoor gate doors need to be self-closing, 3) First Aid Manual is missing, 4) Bathrooms missing shower mats, 5) Hospital beds with rails need to be replaced in bedroom #1, and 6) Bathroom hot water temperature is measuring between 136.5 degrees Fahrenheit and 138.9 degrees Fahrenheit.

The applicant plans on making the necessary corrections and contacting LPA Kim to schedule a follow up pre-licensing inspection.

Exit interview was conducted and a copy of this report was left with Applicant Cristina Coman.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Edward Kim
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025
LIC809 (FAS) - (06/04)
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