<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201665
Report Date: 10/25/2023
Date Signed: 10/26/2023 08:03:38 AM

Document Has Been Signed on 10/26/2023 08:03 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:
10/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:Bory KhamTIME COMPLETED:
04:32 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Steve Chang Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Clinic Manger Bory Kham (BK).

LPA checked 5 client files and 5 staff files. The staff files were found incomplete at the facility.

LPA toured the facility with 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 72 degree F. Hot water temperature was measured at 110 degree F. The temperature of the refrigerator was measured at 40 degree F, and the temperature of freezer was measured at 0 degree F.

Fire extinguisher was serviced on 01/04/2023. 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. The facility had emergency and fire drill on 10/23/2023.

Deficiencies noted today. See LIC809-D. Exit interview was conducted with BK. A copy of this report was provided to BK.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/26/2023 08:03 AM - It Cannot Be Edited


Created By: Chihhsien Chang On 10/25/2023 at 04:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: CROSSROADS VILLAGE
FACILITY NUMBER: 435201665

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the staff files were found incomplete at the facility, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2023
Plan of Correction
1
2
3
4
Administrator stated to submit a plan of correction by the POC due date to make the staff files complete at the facility.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2