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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201665
Report Date: 10/08/2024
Date Signed: 10/08/2024 04:46:27 PM

Document Has Been Signed on 10/08/2024 04:46 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:CROSSROADS VILLAGEFACILITY NUMBER:
435201665
ADMINISTRATOR/
DIRECTOR:		KAREEB HARBINFACILITY TYPE:
735
ADDRESS:438 N. WHITE ROADTELEPHONE:
(408) 254-6848
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 45CENSUS: 37DATE:
10/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Kareeb HarbinTIME VISIT/
INSPECTION COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Steve Chang conducted a case management - incident visit and met with Administrator (ADM) Kareeb Harbin.

On 9/30/2024, the Department received a incident report from the facility. The incident is that on 9/27/2024, a resident R1 made allegations of abused by a staff, and sexual assault, verbal abuse and psychological abuse by staff and residents at the facility.

LPA interviewed Administrator, 4 staff, Resident R1 and another resident R2.

LPA requested R1's physician report, appraisal needs and service plan, and progress notes.

Based on the investigation, the interviews, and records reviewed, the investigation finding of this case management is unsubstantiated.

Exit interview was conducted with ADM. The report was provided to ADM for signature. A copy of the report was provide to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2024
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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