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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700690
Report Date: 11/09/2023
Date Signed: 11/09/2023 03:02:05 PM

Document Has Been Signed on 11/09/2023 03:02 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:CROSSPOINT RESIDENTIALFACILITY NUMBER:
342700690
ADMINISTRATOR:OGENAH, OGIATOR MICHAELFACILITY TYPE:
735
ADDRESS:7504 MOUNTAIN OAK WAYTELEPHONE:
(916) 333-1004
CITY:NORTH HIGHLANDSSTATE: CAZIP CODE:
95660
CAPACITY: 6CENSUS: 6DATE:
11/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Michael Ogenah, AdministratorTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct an annual inspection. LPA met with administrator Michael Ogenah during today's inspection.

LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 3 client rooms, 1 staff room, 1 bathrooms, kitchen, common living spaces, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA toured the backyard and all exits are accessible and unlocked. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable.

LPA reviewed 2 of 6 resident files and 2 staff files. LPA reviewed medications of two residents comparing with physician orders. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current first aid and CPR certificates completed.

Deficiencies cited on 809-D. Appeal rights provided.


Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2023
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 3
Document Has Been Signed on 11/09/2023 03:02 PM - It Cannot Be Edited


Created By: Bethany Mirlohi On 11/09/2023 at 02:47 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
, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: CROSSPOINT RESIDENTIAL
FACILITY NUMBER: 342700690

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not have an approved infection control plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2023
Plan of Correction
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Administrator agrees to complete an infection control plan and send into LPA by 11/30/23.
Type B
Section Cited
CCR
85068.2(b)(1)(F)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (F) The written functional capabilities assessment specified in Section 80069.2.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 2 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2023
Plan of Correction
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Administrator agrees to complete a needs and service plan for C1. Needs and service plan to be sent into CCL by 11/30/23.
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:Troy Ordonez
LICENSING EVALUATOR NAME:Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/09/2023 03:02 PM - It Cannot Be Edited


Created By: Bethany Mirlohi On 11/09/2023 at 02:47 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
, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: CROSSPOINT RESIDENTIAL
FACILITY NUMBER: 342700690

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)(2)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not have an updated LIC610E with required information which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2023
Plan of Correction
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Administrator agrees to complete an updated LIC610E and send into LPA by 11/30/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Troy Ordonez
LICENSING EVALUATOR NAME:Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023


LIC809 (FAS) - (06/04)
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