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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004749
Report Date: 03/11/2022
Date Signed: 03/11/2022 11:06:13 AM


Document Has Been Signed on 03/11/2022 11:06 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:CROSSROADS MANOR, INC.FACILITY NUMBER:
507004749
ADMINISTRATOR:CAPARROS JR, JERRYFACILITY TYPE:
740
ADDRESS:5603 PORTICO DRIVETELEPHONE:
(209) 869-0248
CITY:RIVERBANKSTATE: CAZIP CODE:
95367
CAPACITY:6CENSUS: 6DATE:
03/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Jerry Caparros, JrTIME COMPLETED:
11:15 AM
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On 3/11/22 at 9:51AM, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Jerry Caparros and explained the purpose of the visit.

LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed residential care facility for the elderly with a current census of 6. Facility has 5 bedrooms for residents a formal living room and a dining area off the kitchen LPA also conducted the infection control domain tool.
The facility has an approved COVID Mitigation plan LIC 808 form in place.The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. LPA reviewed three resident records. All first aid/CPR and COVID-19 vaccinations current. All fingerprint clearances verified.

Water temperature reads 110.2*F in the bathroom and room temperature reads 74*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 1-21-22. Facility has an emergency food and water kit. All sharp objects, toxins, and dangerous items were in accessible to residents in care.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held with Jerry Caparros, Jr. and a copy of this report was given to Jerry.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022
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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