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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530250
Report Date: 11/25/2024
Date Signed: 11/25/2024 02:26:55 PM

Document Has Been Signed on 11/25/2024 02:26 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, 744 P STREET, MS 9-14-8201
, CA 95814
FACILITY NAME:CROSSROADS ADULT DAY CARE CENTERFACILITY NUMBER:
365530250
ADMINISTRATOR/
DIRECTOR:		ANDRADE, AUDREYFACILITY TYPE:
775
ADDRESS:11130 WHITE BIRCH DRTELEPHONE:
(909) 481-9663
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91730
CAPACITY: 110CENSUS: DATE:
11/25/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
02:18 PM
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COMP II by CAB successfully completed

Facility Type: ADC
Application Type: CHOW
Capacity: 110
Census (if any clients in care): 0
Method: Telephone call with CAB
COMP II Participants: Audrey Andrade, Administrator/Owner; Shannon Betker, analyst.

Applicant/administrator participated in COMP II at CAB via telephone call with analyst at CAB. Identification of the applicant and administrator was verified by confirming driver’s license number. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Complaints & Reporting
5. Pre-licensing readiness
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Shannon Betker
LICENSING EVALUATOR SIGNATURE: DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
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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