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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004749
Report Date: 03/27/2024
Date Signed: 04/02/2024 05:43:28 PM


Document Has Been Signed on 04/02/2024 05:43 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
03/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jerry Caparros and Czarina CaparrosTIME COMPLETED:
01:30 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 annual visit made out to this facility on 03/27/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Jerry Caparros, who was briefly interviewed.
It was learned that there were (4) residents under the care of hospice at this time.
It was learned that there were other residents who were receiving services through home health as well.
This facility does have a hospice waiver approved for (4) residents since 2020.
This facility also has, on file, a program to accept and retain residents diagnosed with dementia at this time.
Current census was 6 residents.
A tour of this facility was conducted.
Administrator certificate was observed to be present and in compliance at this time for facility designated Administrator Jerry Caparros. Forms and documents were submitted to renew for Certificate #6005959740 that is set to expire on 07/27/2025.
Kitchen area was toured. Cabinets and drawers were reviewed. Food preparation stations, dishwashing station, and other areas intended for meal preps were toured.
Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. This LPA did observe additional food storage units which were present and functional at this time.
A tour of the dining area, living area, and all other areas intended for resident use was conducted.
Medication cabinet, located in hallway closet, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications were discussed with the facility designated Administrator at this time. The medication cabinet was observed to be locked and made inaccessible to the residents at this time.
A tour of the resident bedrooms and restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Grab bars and non skid mats were observed to be present and in good repair at this time.
Hot water temperatures were taken and measured to make sure that they were within the allowed range of
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
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 5


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: 03/27/2024
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
105-120 degrees.
Linen closet, located in the facility laundry area, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 01/15/2024 by the local fire extinguisher company, Assured Fire Extinguisher Services, and in compliance at this time.
First aid kit was observed to be present and contained all of the required components at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gates, and exits was conducted.

A review of (5) facility resident files was conducted and noted on the following LIC 858.
A review of (5) facility personnel files was conducted and noted on the following LIC 859.

The following forms and documents were requested to be updated and submitted into CCL:
  • LIC 308

  • LIC 400

  • LIC 500

  • LIC 610


The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal Rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 04/02/2024 05:43 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in [2] out of [5] facility personnel records did not have proper TB clearance on the LIC 503 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
1
2
3
4
The facility designated Administrator stated that all facility personnel providing care and supervision to the residents will undergo, and receive, an updated medical assessment clearing them of TB from a licensed medical professional. A statement of correction, along with proof of updated TB clearance, will be completed and submitted into CCL by the due date.

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 KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 04/02/2024 05:43 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Night Supervision
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Type A
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that [2] out of [5] facility staff training records did not meet the required number of update annual training hours which posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2024
Plan of Correction
1
2
3
4
The facility designated Administrator stated that all facility staff providing care and supervision to the residents will undergo, and receive, updated annual training to meet the required number of hours with certification on file for review. A statement of correction, along with training topics, name(s) of trainers, and list of attendees with course durations, will be completed and submitted into CCL by the due date of 04/03/2024.
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 KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 04/02/2024 05:43 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that (1) out of (5) facility staff did not have updated certified First Aid training on file which posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2024
Plan of Correction
1
2
3
4
The facility designated Administrator stated that all facility staff providing care and supervision to the residents will be trained and properly certified in First Aid at all times. A statement of correction, along with copies of updated First Aid training cards for the facility staff, will be completed and submitted into CCL by the due date of 04/03/2024.
Type A
Section Cited
CCR
87705(c)(5)(A)
Care of Persons with Dementia
(c) 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in [1] out of [5] facility residents diagnosed with dementia did not have an updated annual medical assessment which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2024
Plan of Correction
1
2
3
4
The facility designated Administrator stated that all residents diagnosed with dementia will be scheduled for a medical appointment with their attending licensed medical professional to obtain an updated medical assessment in order to address any changes in their care needs related to dementia care. A statement of correction, along with copy of updated annual medical assessment, will be completed and submitted into CCL by the due date.
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 KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5