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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000383
Report Date: 03/05/2021
Date Signed: 03/05/2021 04:01:14 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CROSSROADS ELDERLY CAREFACILITY NUMBER:
306000383
ADMINISTRATOR:MICHAEL A. CLAYTONFACILITY TYPE:
740
ADDRESS:12091 ARROYO AVE.TELEPHONE:
(714) 838-1330
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:6CENSUS: 4DATE:
03/05/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Michael ClaytonTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Michelle Reed contacted the facility via telephone to conduct a Case Management visit telephonically due to the COVID-19 Pandemic and pre-cautionary measures. LPA spoke with Administrator Michael Clayton, identified herself and discussed the purpose of the visit. The purpose of the visit was to follow-up on an Unusual Incident/Injury Report that was received in the Licensing office on 2/25/21 regarding Resident #1(R1). Mr. Clayton gave LPA a virtual tour of the facility inside and out.

On 2/14/21 at approximately 7:00 am R1 was found by Caregiver #1 with her right leg lodged between two of the bedrails on her hospital bed. R1 was bleeding and there was no safe way to extract her leg. Staff #1 immediately contacted Administrator Michael Clayton via telephone. Mr. Clayton lives on the premises and he called 911. The paramedics extracted R1's leg from the bed and took R1 to the hospital.

Mr. Clayton stated that he checked on R1 at 2 or 3:00 am and then again at 5:30am. The room was dark and he did not notice that R1 was hurt or hear any cry for help.

R1 received stitches to her leg and returned to the facility the same day. According to Administrator Clayton, the hospital bed provided by the hospice agency was an older model with the rails set further apart. After the incident a new bed was brought to the facility at the hospice agency request.

No citations issued at this time. Mr. Clayton was reminded of reporting injuries or incidents within the 7 day time frame.

An exit interview was conducted with Administrator Michael Clayton via telephone and a copy of this report was provided via email. Administrator agreed to receive the copies of the report and to return a signed copy to LPA Reed.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021
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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