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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006296
Report Date: 04/13/2023
Date Signed: 04/13/2023 03:25:35 PM

Document Has Been Signed on 04/13/2023 03:25 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:CROSS CREEK CAREFACILITY NUMBER:
306006296
ADMINISTRATOR:MANUHUTU, SUANIFACILITY TYPE:
740
ADDRESS:138 E. 18TH STTELEPHONE:
(949) 722-1014
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY: 14CENSUS: 10DATE:
04/13/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:William ManaloTIME COMPLETED:
03:40 PM
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Licensing Program Analysts (LPAs) Sean Haddad and Dwayne Mason Jr. conducted this announced inspection for the purpose of conducting a pre-licensing inspection. LPAs met with Applicant (AP) William Manalo, discussed the purpose of the inspection, and toured the facility. Facility is to operate a Residential Care Facility for the Elderly. Application was submitted to Community Care Licensing on 01/20/2023. This is a change of ownership with persons in care. This is the second pre-licensing inspection. Please see LIC809 dated 03/22/2023.

During the initial pre-licensing inspection, AP stated that the facility currently handles the money for 2 residents. LPA reviewed AP’s application which states that the facility will not handle resident money and that the applicant does not have a surety bond. AP agreed to either stop handling resident money or obtain a surety bond and ensure their application meets all requirements for a facility that handles resident money.

Since the initial pre-licensing inspection, AP obtained a surety bond and updated their application to meet all requirements for a facility that handles resident money. During today’s inspection, LPAs toured the facility with AP, reviewed the surety bond, and reviewed the changes to the application. LPAs confirmed the issue noted during the initial pre-licensing inspection has been addressed.

LPAs explained the process of this application and about the post licensing inspection once the facility is licensed. AP was informed today that the facility is ready for licensure and final approval will be processed by the CAB supervisor in Sacramento. Component III was completed with AP during the initial pre-licensing inspection. An exit interview was conducted and a copy of this report was discussed with and provided to AP.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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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