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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880492
Report Date: 07/12/2024
Date Signed: 07/12/2024 03:22:05 PM

Document Has Been Signed on 07/12/2024 03:22 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:COMMUNITY CROSSINGS INC SAN JACINTOFACILITY NUMBER:
331880492
ADMINISTRATOR/
DIRECTOR:		ANDRADE, AUDREYFACILITY TYPE:
775
ADDRESS:641 N. STATE STREET #1TELEPHONE:
(951) 654-3052
CITY:SAN JACINTOSTATE: CAZIP CODE:
92583
CAPACITY: 60CENSUS: 48DATE:
07/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Audrey Andrade, 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) Yolanda Delgado arrived unannounced to conduct an Annual Inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that forty-eight (48) clients at this facility and there are currently twenty (20) staff. The facility has an Infection Control Plan on file.

Client Records/Incident Reports/Personal Rights/Information- LPAs began review of client records. Five (5) records were reviewed. LPA reviewed for admission agreement, needs and services plan, IPP, medical assessment and TB test results, identification and emergency information, client rights notification and register of clients.

Personnel Records/Training/and Staffing- LPAs began review of employee records. Ten (10) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance, exemptions, transfer of a criminal record clearance, health screening-1 missing and TB test results-4 missing, (8) hours training verification, Administrator continuing education (30) hours every 24 months.



Food Service- Food prep areas are clean and organized. Snacks food items are stored in a cabinet. Emergency food and water supply is present. There is a locked location for chemicals. No sharps are in the kitchen, use of disposable plastic ware only and sharps for office use are locked in storage.

(Continued on Page 2)
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 07/12/2024 03:22 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 07/12/2024 at 03:00 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: COMMUNITY CROSSINGS INC SAN JACINTO
FACILITY NUMBER: 331880492

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in a carbon monoxide detector was not observed and could not be tested which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2024
Plan of Correction
1
2
3
4
Licensee will obtain and maintain a carbon monoxide detector inside the building. LPA will need to return to clear deficiency.
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 07/12/2024 03:22 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 07/12/2024 at 03:00 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: COMMUNITY CROSSINGS INC SAN JACINTO
FACILITY NUMBER: 331880492

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82065(g)(1)
Personnel Requirements
(1) The good physical health of each employee and individual licensee shall be verified by a health screening, including negative test results for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in S1, S2, S3, S4 did not have documentation of a negative TB in staff files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
1
2
3
4
Licensee will ensure staff obtain a negative TB screening and copies will be maintained in staff files and email copies to LPA by POC due date.
Type B
Section Cited
CCR
82066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information: (10) A health screening, as specified in Section 82065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in S4 did not have a health screening in staff file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
1
2
3
4
Licensee will ensure staff obtain a heath screening and copy will be maintained in staff files and email copy to LPA by POC due date.
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024


LIC809 (FAS) - (06/04)
Page: 7 of 7