306003067-1-15-2025-22-AS-BLOZ-DCY3ZR-20250115174158

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003067
Report Date: 01/15/2025
Date Signed: 01/15/2025 05:42:18 PM

Document Has Been Signed on 01/15/2025 05:42 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 III ELDERLY CARE HOME		FACILITY NUMBER:	306003067
ADMINISTRATOR/ DIRECTOR:	MARIA I. JIMENEZ		FACILITY TYPE:	740
ADDRESS:	24252 GRASS STREET		TELEPHONE:	(949) 916-2382
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	01/15/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Administrator Maria Jimenez		TIME VISIT/ INSPECTION COMPLETED:	06:00 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) Brandon Lopez and Licensing Program Manager (LPM) Sheila Santos made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by caregiver staff after explaining the purpose for the visit. Administrator (AD) Maria Jimenez was notified via telephone and later arrived to assist with the inspection. LPA observed that Administrator Maria Jimenez has a valid Administrator certificate which expires on April 20, 2025. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents with a hospice waiver for two. The facility is a two story home with three resident bedrooms, two staff bedrooms, two resident bathrooms, a living room, a dining room, a kitchen, and an attached two car garage. The upstairs portion of the facility is designated for staff only. LPA and LPM, accompanied by the caregiver staff conducted a tour of the physical plant. On today's visit, LPA observed four residents in care and three caregiver staff present. LPA observed the See Something, Say Something poster (PUB 475) mounted on a wall by the kitchen. The PUB 475 poster measured 9 by 14 inches. LPA inspected the three resident bedrooms and they were observed to be free of any hazards. LPA observed the resident bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. Resident linens and blankets were clean. LPA observed additional linens are stored in a hallway closet. LPA inspected the two shared bathrooms. Resident bathrooms are clean. Bathrooms are equipped with grab bars and non skid floor mats. LPA observed that three toxins were stored in an unlocked cabinet in resident bathroom one. LPA observed that one toxin was located in an unlocked cabinet in resident bathroom two. Caregiver staff immediately removed the chemicals and locked it. Hot water temperature measured between 108.1 and 108.9 degrees Fahrenheit. LPA inspected the staff bedroom which was observed to be locked. LPA observed the upstairs staff bathroom to be unlocked. LPA observed six chemical products that were observed to be stored in the staff bathroom. Caregiver staff immediately removed the chemicals and locked it in the staff bedroom. CONTINUED ON LIC809-C

Sheila Santos	TELEPHONE: (714) 703-2857
Brandon Lopez	TELEPHONE: (714) 483-4521
	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SADDLEBACK FMJ III ELDERLY CARE HOME	FACILITY NUMBER: 306003067
	VISIT DATE: 01/15/2025

NARRATIVE

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LPA observed the kitchen has a two day perishable and seven day non perishable food supply on hand. LPA observed kitchen knives are stored in a locked kitchen cabinet. LPA observed cleaning supplies are stored in a locked kitchen cabinet under the sink. LPA observed that three out of the five burners on the gas stove are not in operation. A fire extinguisher is located in a hallway by the kitchen and it was observed the be charged but does not have a maintenance tag.

LPA tested the individual smoke detectors/carbon monoxide detectors which tested operational. The centrally stored medication is kept in a locked cabinet by the kitchen. LPA observed the First Aid kit has all the required components but facility does not have a First Aid manual. The door leading to the attached garage was unlocked at the time of visit. The garage is used for storage and laundry. LPA observed chemicals and toxins to be stored in the garage. LPA observed the facility has an emergency food and water supply stored in the garage.

LPA and LPM, accompanied by caregiver staff conducted a tour of the exterior portion of the facility. LPA observed one pipe, construction materials, three buckets, two trash boxes, and concrete blocks left unattended that may pose a safety issue. LPA observed one ladder was left unattended by the shed. Caregiver staff immediately removed the ladder and locked it in the garage. LPA observed a shaded seating area with furniture for resident use. There is a pool located in the exterior of the facility. The pool is inaccessible to residents and observed to be adequately fenced.

LPA reviewed the four resident files. All the required documentation were present and current in the resident files reviewed. LPA reviewed four residents medication and medication records. LPA reviewed three staff files. LPA observed that Staff #2 (S2) and Staff #3 (S3) are not associated to the facility. Civil penalties assessed. LPA observed that the facility does not have any record of an emergency disaster drill in the last quarter. LPA observed the facility does not currently have liability insurance.

Based on today's observations, the facility is being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Maria Jimenez. A copy of the report was explained and Appeal Rights were provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Brandon Lopez	TELEPHONE: (714) 483-4521
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/15/2025 05:42 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 III ELDERLY CARE HOME	FACILITY NUMBER: 306003067
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care. Administrator Maria Jimenez notified LPA that the facility currently does not have liability insurance.
	POC Due Date: 01/16/2025
	Plan of Correction
1 2 3 4	AD agreed to write and submit a written plan for getting liability insurance to LPA by POC date via fax or email. AD agreed to provide proof of liability insurance within a week and submit it to LPA via email or fax.

Section Cited

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care. LPA observed six chemicals stored in an unlocked staff bathroom upstairs. LPA observed the door leading to the attached garage was unlocked at time of visit. LPA observed chemicals and toxins stored in the garage. LPA observed three toxins stored in an unlocked cabinet in the resident bathroom one. LPA observed one toxin stored in an unlocked cabinet in resident bathroom two.
	POC Due Date: 01/22/2025
	Plan of Correction
1 2 3 4	Caregiver staff immediately removed all toxins and chemicals during the visit. Toxins now inaccessible. In addition a proof of training conducted by the facility adminsitrator to all staff will be provided to LPA via email or fax by the due date.

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

Sheila Santos	TELEPHONE: (714) 703-2857
Brandon Lopez	TELEPHONE: (714) 483-4521
	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/15/2025 05:42 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 III ELDERLY CARE HOME	FACILITY NUMBER: 306003067
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care. LPA observed that the facility has no record of conducting an emergency disaster drill in the last quarter or any previous quarter.
	POC Due Date: 01/16/2025
	Plan of Correction
1 2 3 4	AD agreed to conduct an in house training by POC date. AD will provide the training to LPA via email or fax by POC 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.

Sheila Santos	TELEPHONE: (714) 703-2857
Brandon Lopez	TELEPHONE: (714) 483-4521
	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/15/2025 05:42 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 III ELDERLY CARE HOME	FACILITY NUMBER: 306003067
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Maintenance and Operation

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care. LPA observed that 3 out of the 5 burners on the gas stove do not work. During a tour of the exterior portion of the facility, LPA observed a pipe, construction materials, and two buckets left unattended by the covered patio. LPA also observed boxes of trash, a vacuum, a bucket, and concrete blocks on the sidesouth of the facility. LPA observed a ladder left unattended by the shed.
	POC Due Date: 01/29/2025
	Plan of Correction
1 2 3 4	AD agreed to clear all the hazards and obstructions in the exterior portion of the facility by POC date. LPA will conduct a follow up visit to ensure hazards and obstructions are cleared.

Section Cited

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: (3) 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 and record review, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care. Per file review, LPA observed that Staff #2 is not background associated to the facility. Per file review, Staff #2 started working at the facility on 07/06/2004. Per review of Guardian associations, Staff #2 was seperated from the facility on 02/21/2017 and has not been associated to the facility since. Per file review, LPA observed that Staff #3 is not background associated to the facility. Per file review, Staff #3 started working at the facility on 02/27/2024. Per review of Guardian associations, Staff #3 has never been background associated to the facility.
	POC Due Date: 01/22/2025
	Plan of Correction
1 2 3 4	AD agreed to associate via Guardian Staff #2 and Staff #3 by POC date.

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

Sheila Santos	TELEPHONE: (714) 703-2857
Brandon Lopez	TELEPHONE: (714) 483-4521
	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

LIC809 (FAS) - (06/04)

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