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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001250
Report Date: 05/09/2022
Date Signed: 05/09/2022 12:30:54 PM

Document Has Been Signed on 05/09/2022 12:30 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CRUZ HOUSE IIFACILITY NUMBER:
306001250
ADMINISTRATOR:CARMEN N. CRUZFACILITY TYPE:
735
ADDRESS:23311 CAVANAUGH ROADTELEPHONE:
(949) 581-8526
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 5DATE:
05/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Leovanis & Yaarah, CruzTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required inspection visit. LPA was greeted at the door by Administrator and granted entry. LPA met with Leovanis & Yaarah Cruz, Administrator and explained the nature of the visit.

LPA began the tour of the facility accompanied by Administrator. The facility currently has 5 clients in care. Facility appears clean and sanitary. Facility staff screens all visitors to the facility. Facility keeps documentation in regard to covid for all the staff, visitors and clients. LPA observed facility has covid precautionary posting throughout the facility as well as all required department postings. Facility has an active covid-19 prevention plan in place for the safety of clients in care. LPA observed ample of emergency food and water as well as first aid kits in the facility. Facility has an ample supply of PPE and cleaning supplies. Facility has sanitation precaution in place through out the facility and all common spaces. LPA toured the outside and observed a shaded outside space for client. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation as needed. The facility has completed the LIC808 Mitigation Plan. The Department reviewed and approved the plan on March 12, 2021.

Based on the observations made during today’s visit, no deficiencies were noted today the areas observed per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with Administrator and a copy of this report was provided and left at facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2022
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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