507004749-3-11-2025-27-AS-CYAG-DENMMP-20250311094415

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507004749
Report Date: 03/07/2025
Date Signed: 03/11/2025 09:44:48 AM

Document Has Been Signed on 03/11/2025 09:44 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/ DIRECTOR:	CAPARROS JR, JERRY		FACILITY TYPE:	740
ADDRESS:	5603 PORTICO DRIVE		TELEPHONE:	(209) 869-0248
CITY:	RIVERBANK	STATE: CA	ZIP CODE:	95367
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	03/07/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Jerry Caparros		TIME VISIT/ INSPECTION 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 03/07/2025 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility staff person, Teneisha Morris, who was briefly interviewed at this time. This LPA requested that she go ahead and contact the facility designated Administrator, Jerry Caparros, to inform him that CCL was present at this time for an annual visit. The facility designated Administrator returned back to this facility shortly thereafter while this LPA was conducting this visit. Current census was 6 residents. It was learned that there were (3) residents under the care of hospice at this time. This facility does have an approved waiver to be able to accept and retain up to (4) residents under the care of hospice at any given time. It was learned that this facility has a program to be able to accept and retain dementia residents at any given time. It was learned that there were (5) residents diagnosed with dementia at this time. It was learned that there were (3) residents receiving services through home health at this time. Tour of this facility was conducted. Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Linen closet, located in facility hallway, was reviewed and observed to contain a sufficient supply of towels, sheets, and bedding able to meet the needs of the residents at this time. Kitchen area was toured. Kitchen drawers and cabinets were opened and reviewed. Food supply for 2-day perishable and 7-day nonperishable quantities was reviewed to make sure that they were in compliance at all times. Pantry area was toured. Additional food storage units located in the garage area were observed to be present and functional at this time. Laundry room, located prior to the entrance for the garage, was toured. Bleach, detergent, and all other cleaning supplies were observed to be locked and made inaccessible to the

Liza King	TELEPHONE: (650) 676-0442
Charlie Yang	TELEPHONE: (916) 709-6507
	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

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: 03/07/2025

NARRATIVE

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residents at this time.
Administrator certificate, # 6005959740, for Jerry Caparros was observed to have an expiration date of 07/27/2025 and in compliance at this time.
Forms and documents have been completed in order to renew this Administrator certificate at this time.
Medication cabinet, located in the facility kitchen cabinet, was observed to be locked and made inaccessible to the residents at this time.
First aid kit, located in the office area, was reviewed. This LPA observed that it did contain all of the required components at this time.
Fire extinguishers were located throughout this facility and observed to have been annually inspected by the local fire extinguisher company, Assured Fire Extinguisher Company, on 01/10/2025 and found to be in compliance at this time.
Facility resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Facility resident restrooms were toured. Grab bars and non skid mats were observed to be present and in good repair at this time.
Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees.
A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted.
A review of (2) facility personnel records was conducted on the LIC 859.
A review of (6) facility resident records was conducted on the LIC 858.
The following forms and documents were requested to be updated and submitted into CCL for review by this LPA:
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 King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/11/2025 09:44 AM - 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: 03/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 [1] out of [2] facility staff files did not contain updated annual training hours which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/14/2025
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that all facility staff providing care and supervision to the residents will receive the required number of hours for initial and ongoing training, with documentation on file, at all times. A statement of correction, along with documented proof of updated ongoing training hours, will be completed and submitted into CCL by the 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.

Liza King	TELEPHONE: (650) 676-0442
Charlie Yang	TELEPHONE: (916) 709-6507
	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC809 (FAS) - (06/04)

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