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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600108
Report Date: 11/16/2021
Date Signed: 11/16/2021 05:59:06 PM

Document Has Been Signed on 11/16/2021 05:59 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,
, CA
FACILITY NAME:CROSSROADS RESIDENTIAL CAREFACILITY NUMBER:
385600108
ADMINISTRATOR:BELINDA L. MIGUELFACILITY TYPE:
735
ADDRESS:9 CRYSTAL STREETTELEPHONE:
(650) 756-6221
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY: 10CENSUS: 7DATE:
11/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Belinda Miguel - Licensee/AdministratorTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Licensee/Administrator Belinda Miguel. Clients were present at the facility during this visit. Facility has 1 client who works and 6 clients in day programs.

LPA arrived at the facility and logged into visitor/client’s binder. During facility tour on 11/16/2021 with licensee/administrator Belinda Miguel; facility was found to be at a comfortable temperature with all exits free from obstruction. A sample of client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 01/2021 at the time of the visit. Sample inspection of Smoke & Carbon monoxide detector was found to be operational during the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins are stored in a locked laundry room in the first floor. However, there were 2 out of 3 bathrooms which LPA observed (bathroom number #3 and #2) toxins that were accessible to clients. (see pictures, LIC 809-D) Facility hot water temperature measure between 132.2 degrees F & 133.3 degrees F falling out of Title 22 acceptable regulations of 105 to 120 degrees F in 3 out of 3 clients’ bathroom faucets. (see LIC 809-D) In addition, LPA observed during this visit that showers and bathrooms were not sanitary and a number of debris in the backyard. (see pictures, LIC 809-D) Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. Sample client’s bedrooms have appropriated lighting.

Infection Control:
Facility has submitted a mitigation program plan that has been review and approved at this time. Posters have been placed at entrance and small table with sign-in sheet for visitors and clients. Staff before coming into work has temperature checked. Facility has some PPE supply stored in the staff room. Facility has hired new staff and admitted clients since COVID-19. Clients’ medications are stored and locked in a closet inside staff room. Facility has a 30-day supply of medication for clients.
Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2021
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,
, CA
FACILITY NAME: CROSSROADS RESIDENTIAL CARE
FACILITY NUMBER: 385600108
VISIT DATE: 11/16/2021
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Clients are sometimes wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit. In addition, facility has a designated area for visitors which are being allowed. Clients have also available zoom and telephone calls when contacting with family members and others. Staff have had all PPE training required on file and still working towards acquiring N-95 fit testing.

LPA reviewed Licensing Information System (LIS) with Administrator who stated that is corrected and updated at this time. In addition, LPA advised facility to contact Local County Public Health Immediately if symptoms or COVID-19 + in the facility. Disaster Drills have been conducted monthly with the last one being conducted on 10/20/2021.

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
There were no deficiencies cited at this time.

Department is requesting Licensee to update the following documents and submit to CCLD by 11/30/2021:

LIC 308 Designated of Administrative Responsability
LIC 500 Personnel Summary
LIC 400 Affidavit Regarding Resident Cash Resources
LIC 402 Surety Bond (if applicable)
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate
Copy of Deed and/or Lease of Property
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 11/16/2021 05:59 PM - It Cannot Be Edited


Created By: Carla Fernandes-Goes On 11/16/2021 at 11:59 AM
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
,
, CA

FACILITY NAME: CROSSROADS RESIDENTIAL CARE
FACILITY NUMBER: 385600108

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 3 bathrooms were toxins were found accessible to clients which poses an immediate health, safety or personal rights risk to persons in care. - LPA observed during this visit unlock and accessible cleaning supplies on bathroom #2 and #3 cabinet. (see pictures)
POC Due Date: 11/17/2021
Plan of Correction
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Licensee agrees to ensure that all toxins and danger items are locked and unavailable to clients at all times. Licensee/Administrator removed all items and locked them on a hallway cabinet and laundry room. Licensee will review this regulation with staff at the facility. POC cleared.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 out of 3 clients' bathroom faucets hot water which poses an immediate health, safety or personal rights risk to persons in care. Hotwater temperature at clients' faucets were #1 132.2,#2 132.5, and #3 133.3.
POC Due Date: 11/17/2021
Plan of Correction
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Facility to ensure that hot water temperature stays within Title 22 Regulations of not less than 105 degree F and not more than 120 degree F. Facility to submit self certification that hot water has been adjusted within Title 22 Reg and submit by 11/17/21. In addition,7 day hot water temperature log to be submitted by 11/30/21 in order to clear this citation.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2021


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 11/16/2021 05:59 PM - It Cannot Be Edited


Created By: Carla Fernandes-Goes On 11/16/2021 at 11:59 AM
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
,
, CA

FACILITY NAME: CROSSROADS RESIDENTIAL CARE
FACILITY NUMBER: 385600108

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation & interview, the licensee did not comply with the section cited above clients' bathrooms were unsanitary;number of debris in backyard; and bedroom #3 will need to have ceiling patched which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2021
Plan of Correction
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Facility agrees to ensure that facility is clean, safe, sanitary and in good repair at all times. Facility to have all items from backyard removed, bathrooms cleaned and sanitary, and ceiling in bathroom number 3 patched and submit self-certification to CCLD by POC due date of 11/30/21 stating that all items are in good repair and clean.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2021


LIC809 (FAS) - (06/04)
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