306001250-5-8-2025-22-AS-BLOZ-DGGPLQ-20250508112508

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001250
Report Date: 05/08/2025
Date Signed: 05/08/2025 11:25:19 AM

Document Has Been Signed on 05/08/2025 11:25 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	CRUZ HOUSE II		FACILITY NUMBER:	306001250
ADMINISTRATOR/ DIRECTOR:	CARMEN N. CRUZ		FACILITY TYPE:	735
ADDRESS:	23311 CAVANAUGH ROAD		TELEPHONE:	(949) 581-8526
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY: 6		CENSUS: 5	DATE:	05/08/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:45 AM
MET WITH:	Administrator Leo Cruz Direct Support Professional Yaarah Cruz		TIME VISIT/ INSPECTION COMPLETED:	11:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry into the facility by Direct Support Professional (DSP) Yaarah Cruz after explaining the purpose for today's visit. LPA observed that Administrator (AD) Carmen Cruz has a valid Administrator certificate which expires on October 12, 2026. The facility an Adult Residential Facility (ARF) level 3 licensed for six ambulatory clients. The facility is a two story home with three client bedrooms, all of which are located on the first floor, 1 shared client bathroom, also located on the first floor, five additional bedrooms that are used by the Administrator and their family, a living room, a dining room, a kitchen, and an attached two car garage. LPA, accompanied by the DSP, conducted a tour of the interior portion of the facility. On today's visit, all five clients were away attending their respective Day Programs. LPA inspected the three client bedrooms and observed them to be free of hazards. LPA observed client bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed client beds to have clean linens and blankets. LPA observed linens to be stored in a hallway closet in each client's closet. LPA tested the individual smoke detectors in each of the client rooms which tested operational. LPA inspected the shared client bathroom and observed it to be clear of any hazards. The faucet and toilet was operational. Hot water temperature measured 119.4 degrees Fahrenheit. LPA observed the two bedrooms located on the second floor of the home to be off limits to clients in care and are used by the Administrator's family. LPA observed the doors for the staff bedrooms are kept locked and inaccessible to clients in care. LPA observed the facility has a two day perishable and a seven day nonperishable food supply on hand. CONTINUED ON 809-C

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/08/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 05/08/2025

NARRATIVE

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LPA observed kitchen appliances to be clean and operational. LPA observed kitchen knives and sharps to be stored in a locked kitchen cabinet. LPA tested the individual carbon monoxide detectors which tested operational. There is a Fire Extinguisher located in the kitchen and it was observed to charged and serviced as of December 30, 2024. LPA observed the facility conducted their last emergency disaster drill on March 26, 2025.

The centrally stored medication is kept in a locked kitchen cabinet. LPA observed a First Aid Kit to be stored in the kitchen and it had all the required components. LPA observed the door leading to the attached two car garage to be kept locked and inaccessible to clients in care. LPA observed the garage to be used for storage and laundry. LPA observed chemicals and toxins are stored in a cabinet in the locked garage.

LPA, accompanied by the DSP, conducted a tour of the exterior portion of the facility. The exterior portion was observed to be free of hazards and obstructions. LPA observed a shaded outdoor seating area with furniture for client use. LPA observed the perimeter gates on the north side and southside of the facility to be self latching and can be opened in an evacuation. There are no bodies of water on the premises.

LPA reviewed all five client files. All the required documentation were present and current in the client files reviewed. LPA reviewed clients' medication and medication administration records. LPA reviewed the Personal and Incidental expense monies (P&I) for all five clients. LPA reviewed three staff files. All staff are background cleared and associated to the facility.

Based on the observations made during today's visit, no deficiencies are being cited per the Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Leo Cruz and Direct Support Professional Yaarah Cruz and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/08/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025

LIC809 (FAS) - (06/04)

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