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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002252
Report Date: 09/15/2021
Date Signed: 09/15/2021 03:16:27 PM

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 FMJ II ELDERLY CARE HOMEFACILITY NUMBER:
306002252
ADMINISTRATOR:MARIA OR JOSE JIMENEZFACILITY TYPE:
740
ADDRESS:26732 VIA LINARESTELEPHONE:
(949) 768-5561
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:5CENSUS: 2DATE:
09/15/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Administrator Jose JimenezTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility to conduct a case management. LPA met with Administrator (AD) Jose Jimenez and stated the purpose of this visit.

LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedures. LPA observed two residents in care and two staff members on the floor. LPA toured interior portion of the facility. LPA discussed with AD the Provider Information Notice (PIN) 21-38-ASC: Updated Guidance for the Use of Face Masks, Surgical Masks and Respirators Related to Coronavirus Disease.

For this visit no deficiency was observed, and no citation was issued.

LPA Marin conducted an exit interview with AD J. Jimenez. LPA left a copy of this report , PIN 21-38-ASC, and Facility Transaction Report for review and reference.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
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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