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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603202
Report Date: 11/16/2023
Date Signed: 11/16/2023 02:44:55 PM


Document Has Been Signed on 11/16/2023 02:44 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:CROSSROADS HOME CAREFACILITY NUMBER:
374603202
ADMINISTRATOR:MONTAZER, ARNIFACILITY TYPE:
740
ADDRESS:2512 HEATHER PLACETELEPHONE:
(760) 294-5949
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:6CENSUS: 5DATE:
11/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:12 PM
MET WITH:LEAD CAREGIVER, MARIA THERESA PARAISOTIME COMPLETED:
03:00 PM
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On November 16, 2023, Licensing Program Analyst (LPA), Venus Mixson made an unannounced visit to the facility to conduct an annual licensing inspection, and met with the Lead-Caregiver, Mariatheres Paraiso. The LPA introduced herself and stated the purpose of the visit.

LPA Mixson toured the facility along with the Lead Caregiver, and inspected the facility inside and outside, and there were no obstructions to the indoor or outdoor passageways at the time of this visit. The facility is licensed to serve six senior adult residents, but currently has five residents.
Physical Plant: The facility is a single story home located at 2512 Heather Place, Escondido, Ca. 92027, and the facility phone number is (760) 294-5949, and is operable. The LPA observed the resident's bedrooms, and each was equipped with required furniture as per Title 22. The LPA inspected the facility bathroom, and the hot water temperature tested within regulations. The bathrooms were clean and appliances were operating appropriately at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguisher, and a first aid kit with manual. The LPA observed required postings such as; the Ombudsman poster, "If you See Something, Say Something" and the "Personal Rights" postings were posted in a common area. The cleaning supplies and sharp items were kept locked and inaccessible to the resident. There was a designated space for the resident and staff files. Medications: The medications were, locked, and inaccessible to the resident. The overall facility is clean, and the furniture is in good condition. The facility air conditioning and other appliances were operable currently at the time of this visit. Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there were a variety of food types. Dishes and utensils are in sufficient supply and stored properly. Care & Supervision: Facility has sufficient staff, two caregivers at the time of this visit, and the staff were attentive and engaging the resident, and family visits. Records Review: The LPA reviewed five resident files, two staff files, and conducted two staff interviews. There were no Title 22, Division 6 Regulation violations observed and/or cited during todays visit. An exit interview was conducted and a copy of this report was given to the Facility Manager, Mariatheres Paraiso.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023
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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