507004749-11-8-2021-27-AS-ABOE-C8KRE7-20211108115704

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507004749
Report Date: 11/08/2021
Date Signed: 11/08/2021 11:57:12 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	CROSSROADS MANOR, INC.		FACILITY NUMBER:	507004749
ADMINISTRATOR:	CAPARROS JR, JERRY		FACILITY TYPE:	740
ADDRESS:	5603 PORTICO DRIVE		TELEPHONE:	(209) 869-0248
CITY:	RIVERBANK	STATE: CA	ZIP CODE:	95367
CAPACITY:	6	CENSUS: 3	DATE:	11/08/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Kadian Henry		TIME COMPLETED:	12:10 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	On 11/8/2021 at 10:40am Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Required 1-year Annual inspection. LPA contacted Licensee prior to today's inspection who confirmed no staff or residents have tested positive or shown symptoms within the past 10 days. LPA met with Designated Staff (S1) and was allowed entry into the facility that is licensed to serve a total capacity of 6, today's census is 3. One of one staff observed on site with criminal record clearance in Licensing Information System. LPA observed Administrator Certificate expires on 7/27/2023. Two of two persons on site residing in the facility with criminal record clearance. LPA interacted with a random number of residents during this visit and observed residents. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed kitchen, laundry room, garage, restrooms, bedrooms, and common living areas to be clean and in good repair. LPA observed items not secured accessible to residents including personal care products and cleaning chemicals in residents restroom, knives in kitchen unlocked. S1 locked kitchen cabinet and began to secure toxins during today's visit. The temperature inside the facility was measured at 72F which is within the required range of 68F and 85F, or in areas of extreme heat the maximum shall be 30F less than the outside temperature. The hot water was measured at 110F within regulatory range of is not less than 105F and not more than 120*F. LPA observed the centrally stored medications to be locked inaccessible to residents. LPA observed Centrally Stored Medications Log and all medications stored separately. One of one medications counted matched Centrally Stored. The first aid kit was missing scissors but otherwise in compliance containing at least the following: a current edition of an approved first aid manual, sterile first aid dressings, bandages or roller bandages, adhesive tape, tweezers, thermometers, and Antiseptic solution. S1 stated they would add scissors to the first aid kit. Continued on 809 C.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CROSSROADS MANOR, INC.	FACILITY NUMBER: 507004749
	VISIT DATE: 11/08/2021

NARRATIVE

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Continued from 809.

LPA observed fire extinguisher last inspected on 1/8/2021, smoke and carbon monoxide detectors, central heating and air in the facility. LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. LPA observed COVID precautions signs posted, restrooms stocked with hand soap, hand washing signs posted but no touchless covered trash cans or paper towels. LPA observed 30 day supply of PPE stored is stored.

The facility has an approved Mitigation Plan.

Upon a file review the following items were discussed to be submitted to LPA by 11/20/2021:
Designation of Administrative Responsibility LIC308
Qualifications of Administrator
Personnel Report LIC500
Emergency Disaster Plan LIC610D

Per California Code of Regulations (CCRs) - Title 22, Division 8, the following deficiencies are being cited on the attached 9099D during this visit. A copy of their rights (LIC9058) provided and a signature on this form acknowledges receipt of these rights. Exit interview held and a copy of report provided.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CROSSROADS MANOR, INC.	FACILITY NUMBER: 507004749
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/08/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in that observed items not secured accessible to residents including personal care products and cleaning chemicals in residents restroom, knives in kitchen unlocked which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/19/2021
	Plan of Correction
1 2 3 4	The Licensee agrees to secure all items to maintain compliance with this regulation at all times and submit proof of staff inservice training and pictures to LPA by POC due date.

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021

LIC809 (FAS) - (06/04)

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