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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603202
Report Date: 11/06/2024
Date Signed: 11/06/2024 11:08:10 AM

Document Has Been Signed on 11/06/2024 11:08 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CROSSROADS HOME CAREFACILITY NUMBER:
374603202
ADMINISTRATOR/
DIRECTOR:
MONTAZER, ARNIFACILITY TYPE:
740
ADDRESS:2512 HEATHER PLACETELEPHONE:
(760) 294-5949
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
11/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:ADMINISTRATOR, ARNI MONTAZER
TIME VISIT/
INSPECTION COMPLETED:
11:18 AM
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On November 06, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with the Administrator, Arni Montazer. The facility file review was conducted at the Regional Office and additional records were requested and reviewed on site. The facility is licensed for six and is currently operating at a capacity of four for (740) facility type.

LPA Mixson toured the facility along with the Administrator and made observations pertaining to the annual visit. LPA inspected the facility inside and outside there were no obstructions or debris to the indoor or outdoor passageways at the time of this visit. Additionally, there were no bodies of water on the premises. The facility is a single-story home located at 2512 Heather Place Escondido, CA. 92027.

Physical Plant: The facility phone number is (760) 294-5949 and it is operable. LPA Mixson observed the residents’ bedrooms, and each was equipped with required furniture as per Title 22. LPA Mixson inspected facility bathrooms, and the hot water temperature tested within regulations at 110 and logged. The bathrooms were clean, and appliances were operating appropriately currently at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. LPA Mixson observed required postings such as "If you See Something, Say Something,” the "Personal Rights," and the PUB 475. The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the residents and staff files, and it was locked and inaccessible to residents in care currently at the time of this visit.

Jazmond D HarrisTELEPHONE: (951) 248-0318
Venus MixsonTELEPHONE: (951) 897-7936
DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CROSSROADS HOME CARE
FACILITY NUMBER: 374603202
VISIT DATE: 11/06/2024
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Medications: Were locked and inaccessible to residents in care, and there was a sufficient supply of medication for each resident. The overall facility is clean, the furniture is in good condition. The facility heating system and other appliances were operable currently at the time of this visit. Administrator informed LPA there were safety lights for night throughout the facility, and no fire arms.

Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly, and sharp items are locked.

Care & Supervision/Administration: Adequate staff are present for the supervision of residents in care. Floor plans, telephone numbers and personal rights were found posted in the facility. The listed administrator possesses a current administrator’s certificate with an expiration date of 06/07/2026.

Records Reviewed and Resident/Staff Files: LPA reviewed two staff files and reviewed the facility's staff schedule. The staff files reviewed have criminal clearance and updated training along with First Aid Certification. Four resident file was reviewed and possessed all required paperwork.



Disaster preparedness: LPA Mixson reviewed the facility's emergency and disaster plan as well as disaster training binder. LPA observed the last fire drill met the department standards.

Infection Control: LPA Mixson observed the hand washing stations in the facility restrooms. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found all required infection control measures.



There were technical assistance observed and cited per Title 22, Division 6 of the California Code of Regulations at this time.

An exit interview was conducted where a copy of this report was discussed and given to Administrator, Arni Montazer.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/06/2024 11:08 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: CROSSROADS HOME CARE

FACILITY NUMBER: 374603202

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Section Cited
CCR
1569.626

In addition to paragrah one (1), training requirments shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.
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 [total 5] [ (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care. One out five staff did not receive dementia care training and (2) out of (5) did not receive additional four hours of required training.
POC Due Date: 11/22/2024
Plan of Correction
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The Administrator informed LPA they would have Hospice Nurse complete the required training by the listed POC date.
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.
Jazmond D HarrisTELEPHONE: (951) 248-0318
Venus MixsonTELEPHONE: (951) 897-7936

DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024

LIC809 (FAS) - (06/04)
Page: 2 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: CROSSROADS HOME CARE

FACILITY NUMBER: 374603202

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
HSC
1569.696(a)(2)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: (2) Four hours of training thereafter of in-service training per year on the subject of serving those residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Type A
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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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.
Jazmond D HarrisTELEPHONE: (951) 248-0318
Venus MixsonTELEPHONE: (951) 897-7936

DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024

LIC809 (FAS) - (06/04)
Page: 4 of 4