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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201665
Report Date: 04/10/2024
Date Signed: 04/10/2024 04:25:43 PM

Document Has Been Signed on 04/10/2024 04:25 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
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: 34DATE:
04/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Bory KhamTIME COMPLETED:
11:12 AM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management - incident visit to deliver the investigation finding on that the facility Neglect/Lack of supervision resulted in resident R1's death and met with Clinic Manger Bory Kham (BK).

On 05/16/2023, the Department received a incident/death report from the facility that a resident (R1) was found unresponsive on the floor in the bedroom.

On 05/17/2023, an initial Case Management - Incident investigation visit was conducted. LPA toured the facility with ADM including resident R1's bedroom. R1's physician report, Appraisal Needs and Service Plan, emergency contact, Progress Notes, police report case number, and Admission Agreement were obtained.

On 09/22/2023, the Department interviewed facility staff (S1) at the facility and obtained documents.

On 09/26/2023, the Department reviewed staff records and resident R1's records at the facility, and interviewed Administrator (ADM), 4 staff (S2 - S5) and 1 resident (R2).

On 01/06/2023, the Department interviewed staff (S6) at the facility.

Based on the interviews and records reviews, R1 was admitted to the facility on 12/07/2023. Based on R1's progress note dated 12/08/2022 and 5/02/2023, R1 has a history of drug use and with psychotic disorders. Based on interviews with staff on 09/26/2023, R1 relapsed and was tested positive for drugs during R1's stay at the facility. R1 was prescribed medications which help with the drug cravings, but R1 refused to take it.

Continue on LIC809-C. Page 1 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2024
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 VILLAGE
FACILITY NUMBER: 435201665
VISIT DATE: 04/10/2024
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On 05/09/2023, R1 left the facility to get a routine blood test and came back to the facility around 8:30AM. R1 then had breakfast at the facility. R1 was observed behaving normal during breakfast at the facility. On 5/9/2023, around 10:15AM, R1 was found unresponsive on the floor in the bedroom by a staff during the facility morning resident tracking. 911 was called immediately, paramedics came to the facility and R1 was pronounced dead. Based on R1's medical documents, R1 died due to drug overdose.

Based on the interviews and documents reviewed including treatment plans, progress notes, and medication logs, R1 was provided the proper tools and help to deal with his/her addiction and relapse. R1 did not show obvious critical signs of relapse or being under the influence of substance that would have alerted staff to provide immediate protection for R1. The facility had care team meetings to track and help R1. There is no evidence showing that the facility staff neglect/lack of care and supervision of R1 directly resulting in R1's death.

The department has investigated the incident. Based on the documents reviewed and interviews conducted, the Department found that the allegation neglect/lack of supervision resulted in R1's death
is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur.

No citation was noted today. Exit interviewed was conducted with BK. The report was provided to BK. A copy of the report was provided to BK.


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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC809 (FAS) - (06/04)
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