<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004749
Report Date: 02/23/2023
Date Signed: 02/23/2023 05:36:16 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/23/2023 05:36 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
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: 5DATE:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Jerry CaparrosTIME COMPLETED:
05:45 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 2/23/23 at 3pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required one year annual visit. LPA Jensen met with Licensee Jerry Caparros and explained the purpose of today's visit. The Licensee is also the Administrator of record and holds current Administrator's certificate # 600595740. The facility is licensed for 6 non-ambulatory residents and has a hospice waiver for 2. The annual licensing fees were determined to be current.

LPA Jensen toured the facility and grounds including the kitchen, living room , dining room, bedrooms, laundry room and bathrooms. There is a single designated entrance with a COVID screening station set up. There are COVID infection control signs posted throughout. The facility was observed to be clean and free of odor. The carbon monoxide and smoke detectors were tested and found to be in good working order. The first aid kit was observed to be complete with scissors, tweezers, thermometer, manual and various wound dressings. All staff present were determined to be finger print cleared and associated to the facility.

The facility maintains a 2 day supply of perishable food and 7 day supply of non-perishable food. No food products were observed to be expired. The facility maintains in excess of a 30 day supply of PPE. The facility also maintains an emergency supply of food and water. The knives, medications and cleaning supplies were observed to be locked and inaccessible to residents in care. LPA Jensen interviewed the Licensee who confirmed that they utilize a monthly pest control service. LPA Jensen reviewed the pest control invoice and confirmed that the last pest control service was conducted on 2/21/23. The facility bathrooms were observed to be equipped with grab bars at the toilets and shower. The shower had non-slip flooring. The facility has adequate lighting throughout. The water temperature in the bathroom was within the required regulatory range of 105-120 degrees. The thermostat was set at 74 degrees for the comfort of the resident. LPA Jensen observed an adequate supply of linens.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: 02/23/2023
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
26
27
28
29
30
31
32
Continued from LIC 809....

The grounds were observed to be well maintained and paths were free of obstruction. The backyard has ample seating space and shade for outdoor activities.

LPA Jensen requested an updated LIC 500, a copy of the facility sketch and a current copy of the liability insurance to be emailed to maja.jensen@dss.ca.gov by 3/2/23.

The facility was determined to be in substantial compliance. No deficiencies were issued as a result of this visit.

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2