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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006296
Report Date: 11/20/2025
Date Signed: 12/08/2025 09:32:56 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/02/2023 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230502161524
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: 11DATE:
11/20/2025
UNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Baylon Rhadzivil, Assistant AdministratorTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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Staff do not provide proper medication assistance to resident in care

Staff do not treat resident with respect

Staff is sleeping with resident in care
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the three allegations listed above, LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the purpose of the visit. Assistant administrator Baylon Rhadzivil was present on the premises and assisted with the visit.
Findings for complaint 22-AS-20230424163715 under closed license #306000888 were also delivered during the visit.

The initial investigation visit was conducted by licensing staff on May 4, 2023. During the visit, LPA reviewed and obtained copies of facility and resident records. For this visit, LPA conducted interviews with staff, and reviewed and requested copies of the pertinent records. Additional interviews conducted during a separate visit. Follow-up investigation conducted on October 25, 2023. LPA requested and obtained the facility's census and current roster as well as staff schedules for the months of October and November 2023.
CONTINUED ON FORM LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 22-AS-20230502161524
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/20/2025
NARRATIVE
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CONTINUED FROM FORM LIC9099
Administrator demonstrated the newly operational Medication Administration Records on a tablet and provided the records generated in the previous paper system for the period of January 2023 until October 2023. During the present visit, LPA conducted or attempted a total of four resident interviews in addition to eight staff interviews. Facility resident census and staff roster were requested and obtained. LPA also requested and reviewed records maintained at the facility for five residents, one of which is no longer admitted.

Regarding the allegation that Staff do not provide proper medication assistance to resident in care, the following has been concluded: A majority of statements gathered from residents interviewed demonstrated satisfaction with the assistance provided with the self-administration of medication. None of the residents interviewed stated they had not been provided their medication as prescribed during their admission at the facility. Staff interviews also confirmed the organisation of the medication services and corroborated their ability to provide medication adequately.

Regarding the allegation that Staff do not treat resident with respect, the following has been concluded: Based on interviews conducted with a total of five residents along with multiple staff members, it was determined that a majority of statements gathered did not report any occurrence of inappropriate verbal comments from staff towards residents. No staff members interviewed stated they had ever witnessed inappropriate comments from their co-workers.

Regarding the allegation that Staff is sleeping with resident in care, the following has been concluded: Based on interviews conducted with a total of five residents along with multiple staff members, it was determined that a majority of statements gathered did not report any inappropriate relationships or contacts from staff members with fellow residents. No staff members interviewed stated they had ever witnessed, heard of or gained knowledge of any inappropriate relationships or contacts from staff members with fellow residents.

Based on the evidence gathered, the allegations listed above are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred. No deficiencies cited. An exit interview was conducted and a copy of this report was provided to a facility representative.
This report was amended to correct the allegations investigated.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2