306002252-6-17-2024-22-AS-JCHO-D6BRBU-20240617125320

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002252
Report Date: 06/17/2024
Date Signed: 06/17/2024 12:53:26 PM

Document Has Been Signed on 06/17/2024 12:53 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:	SADDLEBACK FMJ II ELDERLY CARE HOME		FACILITY NUMBER:	306002252
ADMINISTRATOR:	MARIA OR JOSE JIMENEZ		FACILITY TYPE:	740
ADDRESS:	26732 VIA LINARES		TELEPHONE:	(949) 768-5561
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	5	CENSUS: 4	DATE:	06/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Efrain Matheus- Facility Consultant		TIME COMPLETED:	01:20 PM

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) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1 Year Inspection. LPA Cho was greeted and granted entry by Caregiver Clemenciaa Ayala Vasquez followed by a second Caregiver in training, Zindy Carolina Pena Sarabia. Administrators (Admins) Jose and Maria Jimenez were not present as they were out of town. Admin Jose was advised of the visit by telephone at 9:33am. Facility Consultant Efrain Matheus arrived to assist with the inspection. The facility is a two-story structure located in a residential neighborhood. Facility is licensed to operate for five (5) non-ambulatory and maintains a hospice waiver of four (4). There is one (1) resident under hospice care during today's visit. LPA Cho toured the interior and exterior portions of the facility. There are a total of three resident bedrooms and two resident bathrooms on the first floor. The second floor is the residence of the Administrator's family. LPA observed the facility to be clean and sanitary. The resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of of tripping hazards. Smoke/carbon monoxide detectors and auditory exit alarms were tested and operational. LPA observed bathrooms to be in good repair, provided with handrails and a non-skid floor mat. The hot water measured at 113.1 and 113.7 degrees Fahrenheit in the resident bathrooms. Facility met the two day perishable and seven day non-perishable food supply. LPA observed medications, toxins, and sharps were inaccessible to the residents in care. The fire extinguisher was purchased on 11/22/23. For the exterior portion, facility had sufficient seating and shading and the exit door was self-latching and self-closing. LPA observed the emergency disaster supplies including food/water in the garage. Facility did not maintain an emergency drill log. LPA observed the required "See Something, Say Something' (PUB475) posters.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024

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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Document Has Been Signed on 06/17/2024 12:53 PM - It Cannot Be Edited

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: SADDLEBACK FMJ II ELDERLY CARE HOME	FACILITY NUMBER: 306002252
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(1-2)

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interviews, record review, the licensee did not comply with the section cited above in two out of three individuals which poses an immediate health, safety or personal rights risk to persons in care. Immediate civil penalty is assessed.
	POC Due Date: 06/18/2024
	Plan of Correction
1 2 3 4	Adminstrator stated that they will provide proof of clearance for S1 and association of S2 to LPA via email by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024

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: SADDLEBACK FMJ II ELDERLY CARE HOME	FACILITY NUMBER: 306002252
	VISIT DATE: 06/17/2024

NARRATIVE

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LPA conducted an audit of four residents' files and one staff file. LPA did not conduct a staff interview due staff being occupied. No resident interviews were conducted as residents were also occupied. Medications were audited for four residents. No discrepancies noted.

LPA consulted the following: to ensure staff/volunteers/facility representative is fingerprint cleared and associated and to maintain a quarterly emergency drill log accounting for various emergency scenarios.

Based on the observations made during today's visit, a deficiency is being cited as per Title 22 Division 6 Chapter 8 of the California Code of Regulations. An immediate civil penalty is being assessed. An Advisory Note (LIC9102) is being issued during the visit.

An exit interview was conducted with Facility Consultant Efrain Matheus per the acknowledgement of Administrator Jose Jimenez, and a copy of this report including the LIC809C, LIC809D, LIC421BG, LIC811, and the appeal rights were provided during this visit.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024

LIC809 (FAS) - (06/04)

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