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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003067
Report Date: 02/24/2022
Date Signed: 02/25/2022 02:26:31 PM


Document Has Been Signed on 02/25/2022 02:26 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 III ELDERLY CARE HOMEFACILITY NUMBER:
306003067
ADMINISTRATOR:MARIA I. JIMENEZFACILITY TYPE:
740
ADDRESS:24252 GRASS STREETTELEPHONE:
(949) 916-2382
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 5DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Maria JimenezTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Michelle Reed made an unannounced visit to the facility to conduct an Annual visit. Upon arrival LPA met with Staff Rosa Lilia Hernadez and Dulce Ruiz. The focus of the visit was Infection Control. Administrator Maria Jimenez arrived a short time later. The facility was toured with Ms. Hernandez and the following was observed:

Covid signs were posted in the facility and a sanitization station was set up near the front entrance. LPA's temperature was taken upon arrival and a sign in sheet was available. Facility has required Department postings. Administrator Certificate for Maria Jiminez was posted and expired on 4/20/21. According to Ms Jiminez she is still awaiting her certificate. Restrooms observed contained soap, paper towels and toilet paper. Hand sanitizer, soap, wipes and gloves were present and in sufficient supply. The Licensee has at least a 30 day supply of PPE. LPA observed an outside visitation area with ample shading. Residents were observed, having resting in their rooms and others watching tv. Social Distancing and masks were observed. Licensee has required Mitigation plan and Emergency Disaster Plan. Facility has emergency food and water supply. Facility has a secured medication room for resident medication and files. All residents have at least a 30 day supply.

During the visit, LPA consulted with staff regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA advised the importance of mask wearing and hand washing for staff, visitors and residents. Administrators are reminded to review Department PINS in regards to Masking, Staff Testing, Visitation, Dining, Group Activities, Non-essential services, Outings, New Admissions and Entertainment.
No deficiencies noted during visit. An exit interview was conducted and a copy of this report was provided to Maria Jimenez.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
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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