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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202916
Report Date: 01/18/2024
Date Signed: 01/18/2024 11:55:30 AM

Document Has Been Signed on 01/18/2024 11:55 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 AT 650 SOUTH BASCOMFACILITY NUMBER:
435202916
ADMINISTRATOR:HARBIN, KAREEBFACILITY TYPE:
735
ADDRESS:650 S BASCOM AVETELEPHONE:
(669) 319-2410
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 28CENSUS: 0DATE:
01/18/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Kareeb HarbinTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived announced to conduct the pre-licensing visit. LPA met with Kareeb Harbin.

There are no residents on-site. The facility has an approved fire clearance for 28 non-ambulatory residents.

During visit, LPA toured the facility with Kareeb Harbin to include the lobby, resident bedrooms, rest rooms, shower rooms, pharmacy room, office rooms, storage rooms, IT closet, laundry room, kitchen, dining room, common areas, and exterior. All fire exits were free and clear of obstruction. Fire extinguishers were up to date. Facility has carbon monoxide detectors present throughout the facility.

The facility with have a separate entrance for visitors, staff, and residents. The visitor lobby included signs to include but not limited to visitation, grievance, personal rights, and if you see something say something.

Resident bedrooms equipped with beds, clean linens, night stands, lamps, adequate lighting, closets, and lidded trash bins. Room 112 and 113 was approved for 1 bed each per the approved facility sketch. During visit, LPA observed room 112 and 113 was equipped with 2 beds. Room 112 and 113 was equipped with complete furniture to include the list above. Facility was advised to re-submit an updated facility sketch to Centralized Applications Bureau (CAB) for final approval.

The women's and men's bathrooms equipped with toilets, sinks, soap, and paper supplies. Women and men's shower rooms equipped with showers, non-slid floors, and shower chairs. LPA was unable to measure the hot water temperature during visit. LPA scheduled a follow-up visit on 01/22/2024. SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 AT 650 SOUTH BASCOM
FACILITY NUMBER: 435202916
VISIT DATE: 01/18/2024
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Kitchen equipped with plates, bowls, cups, and utensils. Facility has multiple refrigerators and the temperature for each is maintained at 36.0 degrees Fahrenheit. Facility has multiple freezers and the temperature for each is maintained at -07.0 degrees Fahrenheit. LPA observed non-perishable foods. LPA observed the facility's sample menu.

The pharmacy room also known as a medication room, observed with a locked door. The pharmacy room is currently equipped with PRN medications and Personal Protective Equipment (PPE) supplies. Facility's first aid kit observed in the lobby area and observed complete.

Laundry room equipped with laundry appliances. The laundry room will be accessible to clients with staff supervision. Facility will place the chemicals and detergents in a locked storage area.

Facility has an emergency disaster plan to include the name and number of each emergency agency. LPA observed the facility has emergency lighting.

COMP III was waived because Kareeb Harbin is currently an Administrator for another care facility and has experience as an Administrator for 5 years.

Pre-Licensing is incomplete with deficiencies to be resolved by 01/22/2024. A follow-up pre-licensure LIC809 will be generated upon resolution of deficiencies.

This report was reviewed with Kareeb Harbin and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC809 (FAS) - (06/04)
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