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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701279
Report Date: 10/05/2023
Date Signed: 10/05/2023 12:32:11 PM

Document Has Been Signed on 10/05/2023 12:32 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:STANFORD CROSSINGS CARE HOMEFACILITY NUMBER:
392701279
ADMINISTRATOR:DAMRICHOB, ORCHIDFACILITY TYPE:
740
ADDRESS:765 TERN DR.TELEPHONE:
(209) 687-8835
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY: 6CENSUS: 0DATE:
10/05/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Enjola Elma, Cecil Delara, and Orchid Damrichob TIME COMPLETED:
12:30 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
On 10/05/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived announced to conduct a Pre-Licensing visit. LPA was greeted by Licensees, Enjola Elma, Cecil Delara, and Orchid Damrichob.
The facility intends to hold 6 elderly residents, all of which may be non-ambulatory. This facility has a dementia plan on file and has a hospice waiver for 5.
Current census was 0.

Facility Designated Administrator has a current and active certificate #6062089740 and expires on 02/10/2024.
The fire extinguisher, located throughout the facility was serviced on 02/17/2023 by Armor Fire and is in compliance at this time. Carbon Monoxide and smoke detectors were present and in good repair.
Common areas for resident use were toured. Furniture and furnishings were observed to be present and in compliance.
A tour of the bathrooms was conducted. Hot water temperatures were taken to ensure that the hot water being dispensed was within the allowed range of 105-120 degrees at this time. Grab bars were present and functional.
Resident bedrooms were toured. Furniture and furnishing were observed to be present and in good condition.
A linen closet was located in the hallway. LPA observed a sufficient amount of linens at this time.
The kitchen area was toured. Facility freezer and refrigerator showed to be functional and in compliance at this time. A tour of the pantry was conducted. LPA observed that there was a 7-day nonperishable food supply at this time.
Garage area was toured. Laundry detergent and cleaning supplies were locked and made inaccessible at this time. Additional Freezer was identified.
This facility will be using a medication cabinet which was located in the kitchen.
First aid kit was observed to be present and contained all of the required components at this time.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2023
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: STANFORD CROSSINGS CARE HOME
FACILITY NUMBER: 392701279
VISIT DATE: 10/05/2023
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
Laundry room was toured. Additional linens were identified.
Exterior grounds of this facility was toured.
Perimeter fence and gates were observed to be functional and in good repair at this time.
This facility has been observed to be in compliance at this time.

There were no deficiencies observed during the course of this Pre-licensing visit.

Applicant has already conducted Comp I and Comp II.
Comp III was reviewed with applicant.

Exit Interview was conducted and a copy of this report was provided to the applicant at the end of the visit.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2