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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435201665
Report Date: 12/12/2022
Date Signed: 12/12/2022 04:33:08 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/26/2022 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20220726100551
FACILITY NAME:CROSSROADS VILLAGEFACILITY NUMBER:
435201665
ADMINISTRATOR:KAREEB HARBINFACILITY TYPE:
735
ADDRESS:438 N. WHITE ROADTELEPHONE:
(408) 254-6848
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:45CENSUS: 39DATE:
12/12/2022
UNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Bory KhamTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Facility did not provide medical records to resident as requested.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced complaint investigation visit to deliver investigation finding, and met with Clinic Manger Bory Kham (BK).

On 07/26/2022, the Department received a complaint allegation that the facility did not provide a resident's request to obtain copies of his/her medical records.

On 07/29/2022, LPA conducted an initial investigation to interview and obtain documents. A current roaster of clients was obtained. ADM and a resident (R1) were interviewed.

Continued. See LIC9099-C, Page 1 of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022
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 2
Control Number 26-AS-20220726100551
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: CROSSROADS VILLAGE
FACILITY NUMBER: 435201665
VISIT DATE: 12/12/2022
NARRATIVE
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Facility did not provide medical records to resident as requested:
On 07/29/2022, LPA interviewed Administrator (ADM) Kareeb Harbin. ADM acknowledged that the request was received and upon receipt of request, it was sent to their corporate office's Quality Improvement Department via e-mail and /or phone calls.

ADM stated that request didn't have details on what type of documents or records the resident needed. ADM stated their Quality Improvement Department was working with the resident to provide the records/document requested.

During investigation, on 8/9/2022, LPA was notified that the Quality Improvement Department has provided the requested records/documents on 8/4/2022.

On 10/10/2022, LPA interviewed Clinical Manger Bory Kham (BK). BK confirmed that their Quality Improvement Department sent documents to the resident on 7/25/2022 via emails, and continued through 8/4/2022. BK stated that resident confirmed receipt of documents on 8/4/2022.

On 10/10/2022, LPA has confirmed that the resident has received all requested documents on 8/4/2022.

Based on the document reviewed and interviews conducted, The resident received all the records/documents that he/she needs. The facility did pay the effort to meet the resident's needs.

The Department has investigated the above allegation. Based on investigation, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

No citations noted at today’s complaint investigation visit. Exit interview was conducted with BK. A copy of this report was provided to BK.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2