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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000383
Report Date: 03/04/2025
Date Signed: 03/04/2025 04:03:52 PM

Document Has Been Signed on 03/04/2025 04:03 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CROSSROADS ELDERLY CAREFACILITY NUMBER:
306000383
ADMINISTRATOR/
DIRECTOR:		MICHAEL A. CLAYTONFACILITY TYPE:
740
ADDRESS:12091 ARROYO AVE.TELEPHONE:
(714) 838-1330
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY: 6CENSUS: 4DATE:
03/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Administrator Michael ClaytonTIME VISIT/
INSPECTION COMPLETED:
04:18 PM
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Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by care giving staff after explaining the purpose for the visit. Administrator (AD) Michael Clayton was notified via telephone and later arrived to assist with the inspection. LPA observed that Administrator Michael Clayton submitted an Administrator renewal application to the Administrator Certification Bureau (ACB) on June 4, 2024.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents with a hospice waiver for four. The facility is a single-story home with four private resident bedrooms, three shared resident bathrooms, a living room, a family room, a dining room, a kitchen, a laundry room, and an unattached two car garage. LPA accompanied by the AD conducted a tour of the interior portion of the facility. On today's visit, LPA observed four residents in care, one of which is on hospice, and two staff present. LPA observed residents eating in the dining room as well as relaxing in their respective bedrooms. LPA observed the See Something, Say Something poster (PUB 475) in the entryway of the facility. LPA inspected the four private resident bedrooms, and they were observed to be free of any hazards. LPA observed the resident bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. All resident beds had clean linens and blankets. LPA observed additional linens are stored in hallway closet. LPA inspected the three shared resident bathrooms. Resident bathrooms are clean. Bathrooms are equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 111.2 and 111.5 degrees Fahrenheit.

LPA observed the kitchen has a two day perishable and seven day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. The four top electric stove was operational. LPA observed kitchen knives and sharps to be stored in a locked kitchen cabinet. CONTINUED ON LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CROSSROADS ELDERLY CARE
FACILITY NUMBER: 306000383
VISIT DATE: 03/04/2025
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Fire extinguishers are located in the kitchen and in the resident hallway. Fire extinguishers were observed to be charged and purchased on October 9, 2024. LPA tested the individual smoke detectors which tested operational. LPA tested the carbon monoxide detectors which tested operational. LPA observed the facility conducted their last emergency disaster drill on May 9, 2024. The centrally stored medication is kept in a locked storage cabinet in the kitchen. A First Aid kit is stored in the laundry room and it was observed to have all the required components. LPA observed chemicals and toxins to be stored in a locked cabinet in the laundry room. LPA observed an internet device for dedicated resident use in the family room. LPA observed fire places in the living room and in the family room. Fire places were observed to not be in operation at the time of visit.

LPA and AD conducted a tour of the exterior portion of the facility. LPA observed the exterior portion to be clear of obstructions and hazards. LPA observed a shaded outdoor seating area with furniture for resident use. The perimeter gate on the southside of the facility is self-latching and can be opened in an evacuation. The door leading to the unattached two car garage is kept locked and inaccessible to residents in care. The garage is used for storage. LPA observed the facility has a three day emergency food and water supply stored in the garage. LPA observed a pool located in the backyard which is adequately fenced and kept locked for resident safety.

LPA reviewed all four resident files. All the required documentation were present and current in the resident files reviewed. LPA reviewed four residents’ medication and medication records. LPA reviewed two staff files. All staff are background cleared and associated to the facility.

Based on today's observations, deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Michael Clayton. A copy of the report and Appeal Rights were provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/04/2025 04:03 PM - It Cannot Be Edited


Created By: Brandon Lopez On 03/04/2025 at 03:50 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CROSSROADS ELDERLY CARE
FACILITY NUMBER: 306000383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. During facility file review, LPA observed the facility conducted their last emergency disaster drill on May 9, 2024.
POC Due Date: 03/18/2025
Plan of Correction
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AD agreed to conduct an emergency disaster drill and submit proof of completion to LPA via email or fax by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sheila Santos
LICENSING EVALUATOR NAME:Brandon Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
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