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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001399
Report Date: 10/25/2022
Date Signed: 10/25/2022 12:55:52 PM


Document Has Been Signed on 10/25/2022 12:55 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:SADDLEBACK F.M.J. ELDERLY CARE HOMEFACILITY NUMBER:
306001399
ADMINISTRATOR:JIMENEZ, MARIAFACILITY TYPE:
740
ADDRESS:25482 MAXIMUSTELEPHONE:
(949) 380-0797
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 4DATE:
10/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:02 AM
MET WITH:Maria JimenezTIME COMPLETED:
01:10 PM
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On 10/25/2022 at 11:02am, Licensing Program Analyst (LPA) Jessica Cho arrived at Saddleback F.M.J. Elderly Care Home to conduct an unannounced visit. The purpose of today's visit was to conduct a Required 1 Year with an emphasis on Infection Control. At 11:04am, LPA Cho was greeted and granted entry by Licensee/Administrator (Admin) Maria Jimenez. LPA completed the Coronavirus 2019 (COVID-19) screening procedure and also met with Co-Licensee Francisco Jimenez. Caregiver Maria Reyes was also present today. There are no active COVID-19 cases as of today. Facility documents daily temperatures of visitors on a sign in sheet. COVID-19 symptom checks are conducted and documented daily for residents and staff. LPA observed the required COVID-19 precautionary signs were posted in the entryway. The Complaint Poster (PUB475) met the size requirement. The facility is licensed for six non-ambulatory residents and has a hospice waiver for two. There are currently four residents living in the facility of which one is receiving hospice care.

At 11:13am, LPA Cho conducted a tour of the physical plant with Licensee/Administrator Maria Jimenez. The single story home consists of three resident bedrooms and two resident bathrooms. The are three additional private bedrooms and one bathroom utilized by the Administrator's family. The facility also has a living room, TV Room utilized as a family room, kitchen, laundry room, and garage. LPA inspected the resident bedrooms. The resident bedrooms had the required furnishings.The resident bathrooms were checked. Grab bars were secure, the toilets worked properly, the showers were free of mold/mildew, and non-skid mats were in place. Resident bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. LPA observed hand washing signs in the bathrooms. LPA Cho tested the hot water temperatures and the water temperatures measured at 114.9 degree Fahrenheit in Bathroom #1 and 116.4 degree Fahrenheit in Bathroom #2. LPA Cho inspected the kitchen. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
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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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: SADDLEBACK F.M.J. ELDERLY CARE HOME
FACILITY NUMBER: 306001399
VISIT DATE: 10/25/2022
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The fire extinguishers were mounted, fully charged, and purchased on 1/2022. Smoke/carbon monoxide detectors and auditory devices were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the residents. LPA Cho toured the outside grounds. No body of water was present. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards, and there were no security bars or weapons on the premises. The exit gate was self-closing and self-latching. LPA observed sufficient supply of emergency food/water and PPEs.

LPA consulted the following: to ensure the annual licensing fees are paid in full on or before November 5, 2022, to ensure Staff #1 (S1) who is associated to Saddleback FMJ III is associated to this facility, to familiarize the use of Guardian, and to update the Emergency and Disaster Plan for the Residential Care Facilities for the Elderly (LIC610E). LPA verified S1 was associated to Saddleback FMJ III via Guardian during the visit. Admin to submit the Criminal Background Clearance Transfer Request LIC9182 and the Criminal Record Statement (LIC508) to the Community Care Licensing Division by COB 10/25/2022.

Based on the observations made during today's visit, no deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. Advisory Notes (LIC9102s) were issued during the visit. An exit interview was conducted with Licensee/Administrator Maria Jimenez, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
LIC809 (FAS) - (06/04)
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