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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435201665
Report Date: 09/18/2024
Date Signed: 09/18/2024 04:31:05 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
08/08/2024 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20240808123832

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: 36DATE:
09/18/2024
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Lisa GiulianiTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff did not follow reporting requirements.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver investigation finding and met with Licensing and Regulations Manger (LRM) Lisa Giuliani.

On 08/08/2024, the Department received a complaint with the allegation that staff did not follow reporting requirements

On 08/15/2024, the Department conducted an initial investigation visit. LPA interviewed Administrator, 5 staff and 2 residents.

LPA requested resident's physician report, Appraisal Needs and Service Plan, Medical reports and internal incident reports.

Continue on LIC9099-C. page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 26-AS-20240808123832
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 VILLAGE
FACILITY NUMBER: 435201665
VISIT DATE: 09/18/2024
NARRATIVE
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Staff did not follow reporting requirements:

On 08/15/2024, LPA interviewed Administrator (ADM). ADM stated he/she did not send the incident report to CCL office because he/she already called the CCL office for the incident.

LPA interviewed Licensing and Regulations Manager (S1). S1 stated he/she received the internal incident report. S1 stated the facility ADM called CCL office to report the incident. S1 was unable to provide the date and time when the call was made. S1 stated he/she did not send the incident report to CCL office because the facility already called CCL office for the incident.

LPA interviewed staff S2. S2 stated before the facility staff reported the incident to Administrator (ADM) and ADM sent the incident report to CCL office. S2 stated now the facility staff report the incident to Licensing and Regulations Manager and Licensing and Regulations Manager sends the incident report to CCL office.

LPA checked the the facility incident report log reported to CCL office, the facility did not send incident report in writing to CCL office.

The facility did not send the incident report in writing within 7 days to CCL office.

The Department has investigated the above allegation. Based on records reviews, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED. Deficiency is being cited. See LIC9099-D.

Exit interview was conducted with LRM. The report was provided to LRM for signature. A copy of the report was provided to LRM.

Page 2 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 26-AS-20240808123832
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 VILLAGE
FACILITY NUMBER: 435201665
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2024
Section Cited
CCR
80061(b)(1)(E)
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80061 Reporting Requirements(b) Upon the occurrence... a written report containing the information ...shall be submitted to the licensing agency within seven days ... (1)(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
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Licensing and Regulations Manger stated to submit a plan of correction by the POC due date to ensure the facility to send incident report to CCL office in time.
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The requirement was not met as evidenced by:
Based on the interviews and records review, the facility did not send incident report in writing to CCL office which poses a potential health, safety or personal rights risk to a person in care.
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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.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6