435201665-4-16-2024-26-AS-KHOS-D4KMZ4-20240422100232

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435201665
Report Date: 04/15/2024
Date Signed: 04/16/2024 08:03:42 AM

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
11/01/2023 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20231101115440

FACILITY NAME:	CROSSROADS VILLAGE		FACILITY NUMBER:	435201665
ADMINISTRATOR:	KAREEB HARBIN		FACILITY TYPE:	735
ADDRESS:	438 N. WHITE ROAD		TELEPHONE:	(408) 254-6848
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95127
CAPACITY:	45	CENSUS: 35	DATE:	04/15/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Bory Kham		TIME COMPLETED:	10:10 AM

ALLEGATION(S):

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Staff do not treat resident with dignity or respect.
Staff did not give resident medication as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with clinic manager Bory Kham (BK).

On 11/01/2023, the Department received a complaint with the above complaints.

On 11/09/2023, the Department conducted an initial investigation visit. LPA interviewed ADM, 2 staff, and resident R1. LPA obtained LIC500 Personnel Report, resident roster, R1's physician report and Appraisal Needs and Service Plan.

Continue on LIC9099-C. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024

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 26-AS-20231101115440

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: 04/15/2024

NARRATIVE

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Staff do not treat resident with dignity or respect:

On 11/02/2023 and 11/09/2023, LPA interviewed client C1. C1 stated he/she is sensitive and emotional, and easy to get upset. C1 stated he/she has difficulty to express self, staff might not catch what he/she meant. C1 stated he/she might get confused when staff talked to him/her. C1 stated he/she does not feel unsafe in the facility. C1 stated he/she has no complaint against the facility. C1 stated all were due to his/her misunderstandings. C1 stated the facility staff treat him/her nice.

On 11/09/2023, LPA interviewed Administrator (ADM). ADM stated it is hard for C1 to express himself/herself and might interpret wrong what he/she heard. ADM stated sometimes C1 made story. ADM stated he/she and assistant manager are the two that C1 trusts most. ADM stated C1 likes to talk and talked a lot. ADM stated he/she and the facility assistant manager always listen to C1.

LPA interviewed staff S1. S1 stated C1's doctor changed the prescription, and C1 got some confusion about that. S1 stated C1 is emotional and easy to get upset. S1 denied that he/she did not treat C1 with dignity or respect. S1 stated he/she talked to C1 and explained to C1 clearly but C1 was confused. S1 stated the facility clients are all mental disability, and C1 has somewhat difficulty to understand the conversation.

LPA interviewed staff S2. S2 stated the facility staff need to check client every hour. S2 stated during the non-business hours, clients need to stay in the residency area and not in the office areas. S2 stated the facility staff will ask clients to leave the office areas during the non-business hours. S2 stated he/she explained the protocols to C1, but C1 got confused. S2 stated C1 is sensitive and emotional. S2 stated he/she saw C1 yelled at staff, but he/she did not see or hear any staff yelling at C1. S2 denied he/she did not treat C1 with dignity and respect.

A review of C1's clinic admission summary dated 7/6/2023, C1 has auditory hallucinations and visual hallucinations.

Based on records reviewed and interviews, no evidence to indicate that the facility staff did not treat C1 with dignity and respect, and C1 stated he/she did not feel unsafe in the facility.

Continue on LIC9099-C. Page 2 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20231101115440

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: 04/15/2024

NARRATIVE

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Staff did not give resident medication as prescribed :

On 11/09/2023, LPA interviewed staff S1. S1 stated one time he/she brought C1's bedtime medications and morning medications together to C1 but he/she found it immediately and explained to C1 what happened. S1 stated he/she did not administer the bedtime medication to C1.

S1 stated C1's doctor changed one of C1's medications as PRN and the medication sent by the pharmacy was late about 2 months as before. S1 stated C1 was confused about it.

LPA interviewed client C1. C1 stated he/she did not have the bedtime medications during the morning medications hours. C1 stated he/she has no complaint about the facility.

No evidence to indicate the facility staff did not give C1 medication as prescribed.

The department has investigated the above allegations. Based on the documents reviewed and interviews conducted, the Department found that the allegations are 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 allegation did or did not occur.

No citation was noted today. Exit interviewed was conducted with BK. The report was provided to BK. A copy of the report was provided to BK.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024

LIC9099 (FAS) - (06/04)

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