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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880492
Report Date: 12/09/2025
Date Signed: 12/09/2025 11:18:43 AM

Document Has Been Signed on 12/09/2025 11:18 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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: 45DATE:
12/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Armida Gomez, program directorTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Seo Jeon conducted a required annual visit. LPA was greeted and was granted entry and met with Armida Gomez, program director, who was informed of the purpose of the visit.

The facility is a one story building with two (2) activity rooms, three (3) offices, and four (4) bathrooms. The facility does not have a pool or fire arms. The facility is designated as an adult day program serving adults ranging from 18 to 59 years of age. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Infection Control: LPA observed the hand washing stations in the facility had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has a plan for mitigating infectious diseases and training staff on these practices.

Physical Plant: LPA observed the facility physical plant, floors, windows, and doors were clean and fixtures and furniture were present and in good repair. The facility does not have an outdoor activity area. The facility does not have any sharp and dangerous items in the premises. Licensee stated they have passed an annual fire safety inspection and will send fire marshal inspection report to LPA via email by 12-10-2025.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. The facility does not provide food service to clients. LPA observed where client lunch boxes were stored. Continued on LIC809-C.....
NAME OF LICENSING PROGRAM MANAGER: Rikesha Stamps
NAME OF LICENSING PROGRAM ANALYST: Seo Jeon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: COMMUNITY CROSSINGS INC SAN JACINTO
FACILITY NUMBER: 331880492
VISIT DATE: 12/09/2025
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Record Review and Resident/Staff Files: LPA reviewed five (5) staff files and training that contained staff criminal clearance and updated training along with CPR/First Aid. Five (5) client files were reviewed and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: The facility provides assistance with PRN or routine medication for three (3) clients under their physicians' approval and instruction. LPA observed the clients' medication were stored in a locked cabinet in the nurse's station that is inaccessible to the clients in care.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing last fire drill conducted 11-12-2025. LPA observed all facility exits were clear from obstructions.

An exit interview was conducted where a copy of this report was provided to Program Director.
NAME OF LICENSING PROGRAM MANAGER: Rikesha Stamps
NAME OF LICENSING PROGRAM ANALYST: Seo Jeon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
LIC809 (FAS) - (06/04)
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