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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603181
Report Date: 07/12/2024
Date Signed: 07/12/2024 11:38:17 AM

Document Has Been Signed on 07/12/2024 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CROSSDALE RESIDENTIAL HOME, INCFACILITY NUMBER:
198603181
ADMINISTRATOR/
DIRECTOR:		REDJAL, IVY GFACILITY TYPE:
735
ADDRESS:15209 CROSSDALE AVENUETELEPHONE:
(714) 883-8349
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 4CENSUS: 4DATE:
07/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) S Vaid conducted an unannounced annual inspection visit. Upon arrival, LPA met with DSP Eulesa Natulac and explained the reason for the visit. Services provided by Harbor Regional Center. Shortly after, the administrator Ivy Redjal, arrived and discussed the purpose of today's visit. Annual fees are current.

LPA used the Care control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed clients' medications, observed food supply, and reviewed client and staff files.

The facility is a single story house and located in a residential neighborhood area. The facility includes: Living room, dining area, kitchen, laundry room, four clients bedrooms, two clients bathrooms, lounge area and a detached garage. All 4 clients bedrooms were toured. Each client room has one bed, one chair, one night stand, required bed linen, and furniture and sufficient lighting and closet space. All 2 bathrooms were toured and they are clean, sanitary and in a good working condition. The hot water temperature was tested between two bathrooms were tested between 107 and 110.3 which is within the Tittle 22 regulation. The refrigerator in the kitchen and the supply room has 2 days perishable and 7 days non-perishable food supply in the facility. The sharp knives and utensils are stored and locked in the kitchen drawers. All the kitchen appliances are working properly. The common area such as living room and dining area are clean and have the required furniture. The back yard has a shaded area with tables and chairs for clients to utilized. The smoke detectors and carbon monoxide detectors are interconnected and they are working well. All outdoor and indoor passageways are free from obstruction. First aid kit was fully stocked with manual. The last Fire/ Emergency Drill was conducted on 07/02/2024. LPA also reviewed three staff files to confirm health screenings and fingerprint clearances.

Continued on LIC 809 C..next page..
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2024
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CROSSDALE RESIDENTIAL HOME, INC
FACILITY NUMBER: 198603181
VISIT DATE: 07/12/2024
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LPA also inspected 4 clients medication and they are all updated and accurate. LPA reviewed 4 client files to confirm emergency contact is updated on their file. Clients are in the community and were not interviewed.

No deficiencies were cited per California Code of Regulations, Title 22. Exit conference was conducted with administrator. This report, LIC809s, were provided to administrator.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024
LIC809 (FAS) - (06/04)
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