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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202916
Report Date: 01/23/2025
Date Signed: 01/23/2025 12:40:53 PM

Document Has Been Signed on 01/23/2025 12:40 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:CROSSROADS AT 650 S BASCOM AVEFACILITY NUMBER:
435202916
ADMINISTRATOR/
DIRECTOR:		HARBIN, KAREEBFACILITY TYPE:
735
ADDRESS:650 S BASCOM AVETELEPHONE:
(669) 319-2140
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 28CENSUS: 23DATE:
01/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Jose RodriguezTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Christine (Dolores) Kabariti arrived unannounced to conduct the facility's required 1 year annual inspection. LPA met with Program Manager (PM) Jose Rodriguez and Clinic Manager Samantha Tricarico.

During visit, LPA toured the facility with PM to include the resident bedrooms, bathrooms, office space, closets, and common areas. Upon entry, visitors are asked to wear a face mask. All fire exit routes were free and clear of obstruction. Clients observed participating in activities throughout visit. All staff present are fingerprint cleared and associated to the facility roster. Sharp objects, chemicals, disinfectants, and medications observed locked.

Facility temperature maintained at 71 degrees F. Fire extinguishers last serviced on 11/14/2024. LPA entered into rooms #110, 115, and 121. Clients bedrooms observed with beds, linens, adequate lighting, night stand, and closet space. The hot water temperature was measured inside the women's bathroom. Hot water temperature maintained at 109.4 degrees F. Hygiene products observed locked.

Facility kitchen observed locked. Staff observed preparing lunch during visit. LPA observed at least 2 days worth of perishables and 7 days worth of non-perishable foods. Facility has a menu posted in the dining room. Refrigerator temperatures maintained between 35 - 36 degrees F. Freezer temperatures maintained below 0 degrees F. Items inside the refrigerator and freezer observed covered.

See LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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 S BASCOM AVE
FACILITY NUMBER: 435202916
VISIT DATE: 01/23/2025
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LPA observed a refrigerator in the dining room which stores client personal items. The refrigerator has a locking device, however, the device was not locked during visit. PM states the refrigerator was locked previously due to complaints from clients that their items were missing, however, they no longer are experiencing these complaints therefore they no longer lock the refrigerator.

3 client files were reviewed and observed complete. The facility is holding 1 out of 3 resident's P&I money. The resident's P&I money and log was reviewed with the PM and no issues were noted. 3 out of 3 resident's centrally stored medications and records were reviewed and no issues were noted.

3 staff files were reviewed and observed complete. 3 out of 3 staff contains a 1st aid certification. Staff are provided annual training related to their job description.

Facility has an infection control plan. Infection control training is scheduled on the facility's training system. Facility has an emergency disaster plan. LPA observed extra flashlights and batteries. Emergency lighting observed on the walls throughout the facility. Carbon monoxide and smoke detector present. Emergency drills last completed on 12/24/2024.

During visit, the Administrator emailed the requested documents to update the facility's file. LPA obtained a copy of the facility's infection control plan and today's staff schedule.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Program Manager, Jose Rodriguez and Clinic Manager Samantha Tricarico and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC809 (FAS) - (06/04)
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