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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201665
Report Date: 10/21/2021
Date Signed: 10/22/2021 08:49:28 AM

Document Has Been Signed on 10/22/2021 08:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 VILLAGEFACILITY NUMBER:
435201665
ADMINISTRATOR:KAREEB HARBINFACILITY TYPE:
735
ADDRESS:438 N. WHITE ROADTELEPHONE:
(408) 254-6848
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 45CENSUS: 38DATE:
10/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:RCHAEL BARRETO, Program MangerTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Program Manger Rachael Barreto (PM). Upon arrival, the front desk checked LPA's body temperature, and checked LPA in the visitor log book.

LPA toured the facility with PM and clinician Kevin Jahanian. LPA toured the dining area and kitchen. There are 4 resident units and one 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. The current census is 38.

LPA checked the PPE supplies. PPE supplies were observed sufficient. LPA checked the food supplies. 2 day perishable food supplies and 7 day food supplies were observed sufficient. COVID-19 related posters were observed in the facility. Washing hands posters were observed in the restrooms. Staff were observed wearing masks. The trash cans in the common areas and in the rest rooms were not all with covers. PM stated the facility will fix this issue within 2 weeks.

LPA discussed LIC808 with PM. PM stated all staff are fully vaccinated and all residents are fully vaccinated.

No deficiency or allegation was issued today. Exit interview was conducted with PM. This report was provided to PM for signature. A copy of this report was emailed to PM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2021
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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