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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201665
Report Date: 05/17/2024
Date Signed: 05/17/2024 10:21:21 AM

Document Has Been Signed on 05/17/2024 10:21 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
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: 40DATE:
05/17/2024
TYPE OF VISIT:CollateralUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Bory KhamTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Collateral visit and met with Bory Kham, Clinic Manager. The purpose of the Collateral visit was to interview resident R1 as part of a complaint investigation of another licensed facility.

During visit, LPA Marrufo interviewed resident R1.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Bory Kham and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2024
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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