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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701279
Report Date: 01/05/2024
Date Signed: 01/16/2024 10:57:42 AM

Document Has Been Signed on 01/16/2024 10:57 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: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: 4DATE:
01/05/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Cecil De LaraTIME COMPLETED:
10:30 AM
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Unannounced Post Licensing visit made out to this facility on 01/05/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated representative, Cecil De Lara, who was briefly interviewed at this time.
It was learned that this facility just recently discovered that one of their residents had just tested positive for COVID and was taking the necessary steps for isolation and quarantine at this time. This facility was observed to be following the COVID policies and procedures by donning masks and taking temperatures at the entry way into this facility.
It was unsure at this point if other residents had tested negative or were positive. It was also unsure as to the status of the facility staff who were present at this time as well.
As a result, and for precautionary reasons, this LPA did not conduct this Post Licensing visit at this time. This LPA informed the facility representative to keep this LPA updated as to the status of the residents and if there are any new COVID related cases.
This LPA will be back out, at a later date, to conduct and complete this Post Licensing visit.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2024
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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