<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006296
Report Date: 05/29/2024
Date Signed: 05/29/2024 03:07:23 PM

Document Has Been Signed on 05/29/2024 03:07 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: 11DATE:
05/29/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Jarren Manalo, Administrator & Rhadzivil Baylon, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced case management visit to follow up on a Plan of Correction (POC) due on May 22, 2024. LPA was greeted and granted entry into the facility by Assistant Administrator (AAD), Rhadzivil Baylon, and explained the reason for the visit.

The purpose of our visit is follow-up on a Type B Deficiency that was cited on an annual required visit on May 15, 2024. One of three resident bathrooms has a sink that does not allow residents to change the water temperature. Licensee is currently negotiating contracts with two different contractors for all three bathrooms in the facility.

LPA requested proof or documentation that the bathroom sink will be fixed and contractors are being contacted. Administrator (AD) Jarren Manalo stated that they had not chosen a contractor as of their POC date and that most of the conversations are through text messaging directly with owners. LPA requested screenshots with time stamps of contractor texts. AD has provided text conversations regarding the renovations. AD will continue to update LPA with facility renovations once a contractor is chosen and the work is done.

An exit interview was conducted with AD Manalo and AAD Baylon and a copy of this report was provided at exit.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2024
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 1