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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530250
Report Date: 04/27/2026
Date Signed: 04/27/2026 01:10:53 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/04/2025 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250604101659
FACILITY NAME:CROSSROADS ADULT DAY CARE CENTERFACILITY NUMBER:
365530250
ADMINISTRATOR:ANDRADE, AUDREYFACILITY TYPE:
775
ADDRESS:11130 WHITE BIRCH DRTELEPHONE:
(909) 481-9663
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91730
CAPACITY:110CENSUS: 90DATE:
04/27/2026
UNANNOUNCEDTIME BEGAN:
11:34 AM
MET WITH:David Panowicz-Program Administrator TIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Facility did not ensure a client's seatbelt was fastened in wheelchair
Facility did not report incident(s) to Community Care Licensing
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to deliver investigative findings. LPA met with Facility Administrator David Panowicz and explained the purpose of the visit regarding the allegations stated above.

First allegation: Facility did not ensure a client's seatbelt was fastened in wheelchair. Regarding the allegation stated above, LPA conducted an interview with Staff #1 regarding the alleged allegation Staff #1 reported to LPA that on 5/21/2025 Client #1 seatbelt was not properly fastened by staff and as a result Client #1 sustained a fall. Staff #1 informed LPA that on 6/10/2025 staff training for client supervision was conducted and on 8/20/2025 a Zero Tolerance and Vigilant Supervision training facilitated by Inland Regional was also conducted. LPA collected copies of all training documents.

Second allegation: Facility did not report incident(s) to Community Care Licensing.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2026
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 3
Control Number 56-AS-20250604101659
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CROSSROADS ADULT DAY CARE CENTER
FACILITY NUMBER: 365530250
VISIT DATE: 04/27/2026
NARRATIVE
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Regarding the allegation stated above, LPA conducted an interview with Staff #1 regarding the alleged allegation Staff #1 informed LPA that a Special Incident Report (SIR), was completed and reported to the required agency. Staff #1 provided LPA a copy of the Special Incident Report (SIR), during SIR review LPA observed that the facility did not report the incident involving Client #1 to Community Care Licensing. Based on the evidence gathered during the investigation, the above allegations are Substantiated. A finding that the complaint is Substantiated means that the findings are valid because the preponderance of the evidence standard has been met. Title 22 Regulations Personnel Qualifications and Duties 82065.1 (a)(1)(2), Reporting Requirements (a)(1)(B), from division 6, chapter, article 6, is, cited on the attached LIC 9099 D.

An exit interview was conducted where this report, appeal rights, and LIC9099-D was discussed, and a copy of the report was provided to Facility Administrator David Panowicz at the conclusion of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20250604101659
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CROSSROADS ADULT DAY CARE CENTER
FACILITY NUMBER: 365530250
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2026
Section Cited
CCR
82065.1(a)(1)(2)
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82065.1 Personnel Qualifications and Duties ...(a) The following requirements shall apply to direct care staff as defined in Section 82001(d): (1) Direct care staff shall be responsible for care and supervision of clients, as defined in Section 82001(c)....(2) Direct care staff shall not be assigned to any of the support staff duties specified in Section 82065.1(b) unless the care and supervision needs of clients have been met.

This requirement is not met as evidence by:
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The Licensee has agreed to provide training on regulation "Personnel Qualifications and Duties (a)(1)(2)" to all staff and touch topic on the importance of client supervision. Licensee will provide training to LPA on POC date 5/20/26.
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Based on interviews and review of record, the licensee did not adhere to Personnel Qualifications and Duties regulation which results in Client #1 to sustain a fall, which poses an immediate health, safety, or personal rights risk to clients in care.
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Type B
05/20/2026
Section Cited
CCR
82061(a)(1)(B)
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82061 Reporting Requirements...(a) Upon the occurrence, during the hours the day program is providing services to the client, of any of the events specified in Section 82061(a)(1), a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in Section 82061(a)(2) shall be submitted to the licensing agency within seven days following the occurrence of the event....(1) Events reported shall include, but not be limited to, the following: (B)...Any injury to any client which requires medical treatment;

This requirement is not met as evidence by:
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The Licensee has agreed to provide training on regulation "Reporting Requirements 82061 (a)(1)(B)" to all staff. Licensee will provide training to LPA on POC date 5/20/26.
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Based on interviews and review of record, the licensee did not adhere to Reporting Requirements regulation and report incident involving Client #1 to CCL Department, which poses an immediate health, safety, or personal rights risk to clients in care.
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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.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2026
LIC9099 (FAS) - (06/04)
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