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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006296
Report Date: 05/15/2024
Date Signed: 05/15/2024 01:26:58 PM

Document Has Been Signed on 05/15/2024 01:26 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:CROSS CREEK CAREFACILITY NUMBER:
306006296
ADMINISTRATOR/
DIRECTOR:		MANALO, JARRENFACILITY TYPE:
740
ADDRESS:138 E. 18TH STTELEPHONE:
(949) 722-1014
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY: 14CENSUS: 10DATE:
05/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Jarren Manalo, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Suani Manuhut, Resident Care Coordinator. During today’s visit, LPA met with Jarren Manalo, Administrator and Rhadzivil Baylon, Assistant Administrator.

The facility is a two story building with an approved fire clearance of fourteen ambulatory; eleven non-ambulatory residents of which eleven may be bedridden. The facility currently has a census of ten residents in care.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in three resident bathrooms, and testing auditory devices on all exits. The hot water temperature measured between 112.5 and 118.2 degrees Fahrenheit and smoke detectors were operational. The facility’s last fire drill was conducted on April 1, 2024. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review completion medications appear to be being given as prescribed.

LPA reviewed six of twelve staff training and fingerprint records. LPA reviewed seven of ten resident records. LPA interviewed five alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on April 19, 2025.

The following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with Jarren Manalo and a copy of this report was given to the facility along with a copy of the LIC 858; 859;809-D and Appeal Rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
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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Document Has Been Signed on 05/15/2024 01:26 PM - It Cannot Be Edited


Created By: RoseMarie Ruppert On 05/15/2024 at 01:12 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: CROSS CREEK CARE
FACILITY NUMBER: 306006296

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Licensing Program Analyst (LPA) observation, the licensee did not comply with the section cited above in one out of three resident bathrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2024
Plan of Correction
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Administrator will speak with contractor to expedite renovating bathroom sinks so that water temperature can be controlled by person using faucet. Administrator will email the contractor's information to LPA and update on progress.
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:Alisa Ortiz
LICENSING EVALUATOR NAME:RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024


LIC809 (FAS) - (06/04)
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