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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001250
Report Date: 12/11/2024
Date Signed: 12/11/2024 03:15:15 PM

Document Has Been Signed on 12/11/2024 03:15 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CRUZ HOUSE IIFACILITY NUMBER:
306001250
ADMINISTRATOR/
DIRECTOR:		CARMEN N. CRUZFACILITY TYPE:
735
ADDRESS:23311 CAVANAUGH ROADTELEPHONE:
(949) 581-8526
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 5DATE:
12/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Leo Cruz, Administrator
Yaarah Cruz, Administrator		TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Brandon Lopez conducted an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPAs were greeted and granted entry by facility administrator Leo Cruz and Direct Service Provider Yaarah Cruz after introducing themselves and stating the purpose of the visit.

The facility is an Adult Residential Facility licensed for six ambulatory clients. There are currently five clients in care. Upon arrival on the premises, all five clients are attending their respective day programs. During the visit, clients are observed returning from program and relaxing in their bedrooms or in the facility's common areas. LPAs conducted two client interviews and two staff interviews during the visit.

The facility is a two-story home. Clients occupy three shared bathrooms on the facility's ground level. There are two additional bedrooms with en-suite bathrooms on the same level for use by the administrator and their family. Clients share one common bathroom. The upper level is for use by staff and their family only as verified during the visit. Upper level includes two additional bedrooms and a closet space. The facility's interior appears clean, safe, and sanitary. All clients’ rooms had required elements, including bed, chair, closet space, and ample lighting. Hot water measured at 114F.

LPAs observed the facility had a two-day supply of perishables and a seven-day supply of non-perishable food available as required by regulations. Clients are observed being provided snacks and drinks upon their return from program.

LPAs observed hallways and walkways were free of obstructions. There are no bodies of water on the premises. The backyard is observed to have outdoor furniture and a shaded area that can be used by the clients. The route of egress is free of obstructions and all tools and potentially dangerous items are secured from being accessed by the clients in care.
CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 11/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CRUZ HOUSE II
FACILITY NUMBER: 306001250
VISIT DATE: 12/11/2024
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CONTINUED FROM LIC809
LPAs observed a fire extinguisher present in the dining room. It is charged, however the maintenance tag has been expired since August 2023. Consultation provided on Technical Violation Advisory Note form attached. Staff and LPAs tested smoke and carbon monoxide detectors which were found to be operational. Sharp instruments are stored in a locked drawer in the kitchen. Cleaning supplies and laundry area and products are stored in the locked garage. Medication for each client is kept locked and secured in a locked cabinet in the kitchen.

LPAs reviewed all five clients’ files and medications as well as P&I records which were verified to correspond to the amount noted on the ledgers. Receipts also match the amounts and dates logged in the ledger. LPAs reviewed three staff files. All current staff members are cleared and associated.

The Emergency and Disaster Plan was reviewed along with documentation of fire and emergency drills conducted quarterly. The facility follows infection control and surface/hand washing precautions however it does not have an Infection Control Plan in place. Technical Violation Advisory Note provided along with a copy of the current LIC9282 form.

No deficiencies are cited during today's inspection visit. Two consultations were provided on Technical Violation Advisory Notes regarding the Infection Control Plan and fire extinguisher maintenance. An exit interview was conducted and a copy of this report was provided to the facility staff.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC809 (FAS) - (06/04)
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