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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002252
Report Date: 05/10/2022
Date Signed: 05/10/2022 04:49:20 PM


Document Has Been Signed on 05/10/2022 04:49 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 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:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Jose JimenezTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Jessica Cho made an unannounced required annual (mitigation) inspection in this facility. LPA was greeted and granted entry by Administrator (Admin) Jose Jimenez, and LPA completed the Coronavirus 2019 (COVID-19) screening procedure. LPA stated the purpose of the visit and toured the facility with the Admin.

The facility is a single level structure and licensed for five non-ambulatory residents and has a hospice waiver for four residents. There is one resident in hospice care as of today. For this visit, there are two residents in care and one staff member on duty. LPA toured the interior and exterior portions of the facility. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke detectors, carbon monoxide, and auditory exit alarms tested operational. LPA observed bathrooms to be in good repair; and provided with handrails and a nonskid - floor mat. Hot water was measured at 115.1 degrees Fahrenheit in Bathroom #1 and 116.3 degrees Fahrenheit in Bathroom #2. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. LPA observed sharp items and medications were inaccessible to the residents in care. The fire extinguisher was mounted and charged. For the exterior portion, facility had outdoor furniture under a patio umbrella. The exterior grounds were free of tripping hazards and the side exit door was self-latching and self-closing. LPA reviewed the approved COVID-19 Mitigation Plan. LPA discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.
For this visit, there are no deficiencies cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit, and the licensee will follow-up with the corrections. An exit interview was conducted with Administrator Jose 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: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
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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