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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000383
Report Date: 07/21/2022
Date Signed: 07/21/2022 01:35:49 PM


Document Has Been Signed on 07/21/2022 01:35 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
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:
07/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Herminia Martinez TIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection in this facility. LPA met with staff Herminia Martinez and stated the purpose of this visit. Administrator Michael Clayton arrived after the inspection.

The facility is a single level structure and licensed for six non-ambulatory with a hospice waiver for four. This facility is a Residential Care Facility for the Elderly/Hospice.

At about 12:05 PM, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed 4 residents in care and one staff member on duty. LPA toured the interior and exterior portions of the facility. There were 4 private resident rooms. Resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors and carbon monoxide were tested to be operational. LPA noticed that auditory exit alarms were not operational. Administrator was made aware of this and will have them replaced. Bathrooms (1 – 3) was observed to be in good repair and provided with grab bars and hot water was measured between 115.7 degrees and 117.6 degrees Fahrenheit. LPA noticed in restrooms 1 and 2 there were no handwashing signs. LPA informed Administrator and will have signs promptly posted. LPA notice PUB 475 See Something, Say Something sign was not proper size of 20x26 inches. LPA made Administrator aware. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements, cleaning supplies and sharp items were inaccessible to residents in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was observed. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. The exterior portion of the facility also contained a swimming pool with gate surrounding the pool and a locked gate. The exterior portion did contain an outdoor office. Garage is kept locked and used for storage and emergency supplies. Laundry room is on the other side of the kitchen and was in good repair with an operational washer/dryer.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward TapiaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022
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


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 306000383
VISIT DATE: 07/21/2022
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Kitchen was in good repair with medications and sharps kept locked. LPA Tapia reviewed the COVID 19 mitigation plan and the Emergency disaster plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed. No citation was issued. Two advisories were issued today.

LPA Tapia conducted an exit interview with Administrator Michael Clayton and copy of this report was explained and left at the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward TapiaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC809 (FAS) - (06/04)
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