507004749-6-14-2024-27-AS-CYAG-D68LHP-20240614084641

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507004749
Report Date: 06/13/2024
Date Signed: 06/14/2024 08:46:54 AM

Document Has Been Signed on 06/14/2024 08:46 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

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: 5	DATE:	06/13/2024
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Jerry Caparros		TIME COMPLETED:	03:30 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	Unannounced Plan of Correction visit made out to this facility on 06/13/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator Jerry Caparros. A brief interview was conducted with the facility designated Administrator at this time. Current census was 5 residents. The purpose of this visit was to follow up on the deficiencies that were cited from a prior visit conducted on 03/27/2024 and to follow up on the Plan of Correction. The following deficiencies were observed and cited on 03/27/2024: All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CROSSROADS MANOR, INC.	FACILITY NUMBER: 507004749
	VISIT DATE: 06/13/2024

NARRATIVE

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Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. (A) When any medical assessment, appraisal, or observation indicates that the resident's dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident.

Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This facility did complete the Plan of Correction and provided all of the required forms and documents at this time.

Plan of Correction clearance letters were printed and copies were provided to the facility designated Administrator at this time.

There were no further deficiencies observed or cited during today's Plan of Correction visit.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

LIC809 (FAS) - (06/04)

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