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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000383
Report Date: 06/06/2025
Date Signed: 06/06/2025 04:39:41 PM

Document Has Been Signed on 06/06/2025 04:39 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: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
06/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Administrator Michael ClaytonTIME VISIT/
INSPECTION COMPLETED:
04:54 PM
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On June 6, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility 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 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) mounted on the wall in the resident hallway. 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 115.7 and 117.2 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. CONTINUED ON LIC809-C
Sheila SantosTELEPHONE: (714) 703-2857
Brandon LopezTELEPHONE: (714) 483-4521
DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2025
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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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: CROSSROADS ELDERLY CARE
FACILITY NUMBER: 306000383
VISIT DATE: 06/06/2025
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The four top electric stove was operational. LPA observed kitchen knives and sharps to be stored in a locked kitchen cabinet. Fire extinguishers are located in the kitchen, in the resident hallway, in the laundry room, and in the unattached two car garage. 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 individual carbon monoxide detectors which tested operational. LPA observed the facility conducted their last emergency disaster drill on March 17, 2025.

The centrally stored medication is kept in a locked storage cabinet in the laundry room. 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 separate 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 be adequately fenced and 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 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, no deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Michael Clayton and a copy of the report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Brandon LopezTELEPHONE: (714) 483-4521
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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