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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201665
Report Date: 10/28/2024
Date Signed: 10/28/2024 05:24:09 PM

Document Has Been Signed on 10/28/2024 05:24 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: 39DATE:
10/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:42 PM
MET WITH:Julia PhillipsTIME VISIT/
INSPECTION COMPLETED:
04:53 PM
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Licensing Program Analyst (LPA) Steve Chang Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Director of Quality Improvement Julia Phillips (JP) and Clinic Manger Bory Kham (BK).

LPA checked 5 client files and 5 staff files. 4 out 5 staff files were observed without training log information, JP stated the document were in the Corporate. 1 out 5 resident files was observed without Appraisal Needs and Service Plan. JP stated he/she will send 4 staff training log document and 1 resident Appraisal Needs and Service Plan to LPA.

LPA toured the facility with JP and BK. License, Administrator Certificate and Personal rights were observed at main entrance. LPA toured the dining area and kitchen. 2 days perishable food supplies and 7 nonperishable food supplies were observed sufficient. LPA toured the Administration unit and resident units with BK. There are 4 resident units and two staff unit. Each resident unit has a big living room, Med office, Laundry room, rest rooms and office area. Unit A has 5 shared rooms and 2 single rooms. Unit B has 3 shared rooms and 4 single rooms. Unit C has 4 shared rooms and 2 single rooms, Unit D has 5 shared rooms and 3 single rooms. Cleaning products room, knives box, medication rooms were observed locked.

Room temperature was at 69 degree F. Hot water temperature was measured at 112 degree F. The temperature of the refrigerator was measured at 37 degree F, and the temperature of freezer was measured at -4 degree F.
Fire extinguisher was serviced on 10/16/2024. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by BK, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways. There are 2 storage rooms at the backyard. The facility had emergency and fire drill on 10/16/2024.
Exit interview was conducted with JP. The report was provided to JP for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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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