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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001250
Report Date: 04/13/2023
Date Signed: 04/14/2023 06:51:39 AM

Document Has Been Signed on 04/14/2023 06:51 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
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:
04/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Leovanis "Leo" CruzTIME COMPLETED:
11:00 AM
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Licensing Program Analysts (LPA) Lydia Martinez made an unannounced visit to conduct a Required – 1 Year inspection. Upon arrival LPA was greeted by facility Staff Yaraah Cruz and Administrator Leovanis Cruz. LPA began inspection with introduction and visit purpose. There are currently 5 Clients residing at the facility. One client and three staff were present during today's visit. Per staff, four clients are at Day Program. Client appeared happy and well cared for.

LPA Martinez, along with Staff conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, living room, garage and observed the following:

Facility is a two story 7 bedroom, 4 bathrooms with an attached 2 car garage that is used for storage. LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. LPA observed a table and chairs in back porch area for clients and visitors. Client bedrooms are double occupancy and were observed to be spacious and easily accommodate furnishings such as lamps, chair, dresser and a bed. Bathrooms were observed to be clean, have a supply of soap and paper towels. Hot water temperature was within regulatory requirements. Linen and hygiene supplies were stocked. Emergency Phone Numbers and Exit Plan were reviewed. Food prep area is clean and organized. Food supply meets the requirement of one (1) week supply of non-perishable and two (2) day supply of perishables. Smoke detectors and carbon monoxide detectors were found to be operational. Fire Extinguishers were charged and mounted and were last serviced on 08/02/2022. LPA reviewed facility's Emergency Disaster/Fire drill log that shows last fire drill was on 03/16/2023. Stove burners, microwave, washer, and dryer are operational. Chemicals and sharps are made inaccessible to the clients. Laundry is done in the garage. Medications are centrally stored in a locked kitchen cabinet. Medications reviewed appear to have been dispensed accurately.

(see LIC809C)
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CRUZ HOUSE II
FACILITY NUMBER: 306001250
VISIT DATE: 04/13/2023
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LPA Martinez observed the Emergency and Disaster and Evacuation plan. Facility has a supply of emergency food, water and PPE in storage closet and readily available for staff and clients.

First-Aid Kit had all the required elements. There is a land line in the facility.

LPA reviewed client files and staff files. LPA interviewed 1 client and 2 staff. The clients P&I records were reviewed, individual log is maintained for each client. All monies are accounted for and logs were kept to date.

Indoor and outside passageways are free of obstruction.

In order to update CCL file, please provide the following updated documents to CCL by 04/25/2023: 1.) Designation of Administrative Responsibility (LIC308) 2.) Personnel Report (LIC500); 3.) Emergency Disaster Plan (LIC610D); 4.) Surety Bond; and 5.) Administrator certificate.



Based on observations made during today's visit in the areas reviewed, there are no deficiencies being cited per Title 22, Division 6 of The California Code of Regulations. Copy of this report will be sent to email on file.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC809 (FAS) - (06/04)
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