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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006296
Report Date: 08/02/2023
Date Signed: 08/02/2023 02:52:14 PM

Document Has Been Signed on 08/02/2023 02:52 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:MANALO, JARRENFACILITY TYPE:
740
ADDRESS:138 E. 18TH STTELEPHONE:
(949) 722-1014
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY: 14CENSUS: 10DATE:
08/02/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:32 PM
MET WITH:Jarren Manalo- Administrator TIME COMPLETED:
03:15 PM
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 On this day Licensing Program Analyst (LPA) Andrea Mendivil, made an unannounced visit to Cross Creek Care in conjunction with a complaint visit control number 22-AS-20230802100821. The purpose of this visit was to conduct a health and safety evaluation.

Residents in care appeared to be safe, no imminent health and safety hazards were observed. LPA observed residents in their respective rooms and in the activity room. LPA observed residents to be well groomed and no visible injuries noted.

No deficiencies were cited during this visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2023
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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