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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006296
Report Date: 03/14/2025
Date Signed: 03/14/2025 04:51:25 PM

Document Has Been Signed on 03/14/2025 04:51 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:		BAYLON, RHADZIVILFACILITY TYPE:
740
ADDRESS:138 E. 18TH STTELEPHONE:
(949) 722-1014
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY: 14CENSUS: 12DATE:
03/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:55 PM
MET WITH:Jarren ManaloTIME VISIT/
INSPECTION COMPLETED:
05:00 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
On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 14 ambulatory residents of which 11 may be non-ambulatory and bedridden. Facility has an approved hospice waiver for 6 residents and the home currently has 12 residents. Administrator (AD) Jarren Manalo and Assistant Administrator Rhadzivil Bayon conducted facility tour. AD Manalo has a valid certificate that expires on 4/19/2025.

LPA along with Administrators toured the facility at 2:10 PM. LPA toured the physical plant, checked food service, facility documentation and the first aid kit. The facility consists of 8 resident bedrooms, living room, dining room, 2 staff rooms, staff kitchen, and resident kitchen as well as 3 resident bathrooms. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 107.7 degrees F and 113.9 degrees F in all bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. At 2:15pm, LPA observed 2 laundry detergent containers accessible in the second floor balcony through an unlocked door. LPA toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. Fire sprinkler system was serviced April 2024. LPA reviewed the emergency disaster plans and plan is complete and thorough. Facility conducts quarterly emergency drills with the last drill conducted on 1/17/2025. Outside grounds were toured. There are no observed security bars or weapons on the premises. First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of exercise, games, and music therapy. There is shaded outdoor seating for residents. LPAs observed the emergency food and water supply. LPA reviewed five resident files and three staff files.
Continued on LIC809C dated 3/14/2025
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2025
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 306006296
VISIT DATE: 03/14/2025
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
26
27
28
29
30
31
32
All resident files contained required documentation including admission agreements, physician reports, resident appraisals, and physician orders for bed rails as indicated. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPA reviewed medication storage and administration. Medications are stored in a locked cabinet in the first floor and extra medication is locked in a secondary cabinet upstairs.

Based on the observations made during today’s visit, the following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/14/2025 04:51 PM - It Cannot Be Edited


Created By: Fred Arias On 03/14/2025 at 04:24 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: 03/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation, 2 laundry detergent bottles were left out on the second floor balcony which was accessed through an unlocked door which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/15/2025
Plan of Correction
1
2
3
4
Facility moved laundry detergent into a locked cabinet in the balcony during the visit.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Fred Arias
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2025


LIC809 (FAS) - (06/04)
Page: 2 of 5