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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701279
Report Date: 11/13/2024
Date Signed: 11/19/2024 01:34:41 PM

Document Has Been Signed on 11/19/2024 01:34 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:STANFORD CROSSINGS CARE HOMEFACILITY NUMBER:
392701279
ADMINISTRATOR/
DIRECTOR:
DAMRICHOB, ORCHIDFACILITY TYPE:
740
ADDRESS:765 TERN DR.TELEPHONE:
(209) 687-8835
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY: 6CENSUS: 6DATE:
11/13/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:John ForondaTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Unannounced Plan of Correction visit made out to this facility on 11/13/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated representative John Foronda. A brief interview was conducted with the facility designated representative at this time.
Current census was 6 residents.
The purpose of this visit was to follow up on the deficiencies that were cited from a prior annual visit conducted on 10/16/2024. This visit was to follow up on the Plans of Correction that were due.

The following deficiencies were observed and cited on 10/16/2024:

Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment.
  • The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

  • The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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

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

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

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2024
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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