306003067-1-24-2024-22-AS-CDPO-CZSRPL-20240124121208

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003067
Report Date: 01/24/2024
Date Signed: 01/24/2024 12:12:19 PM

Document Has Been Signed on 01/24/2024 12:12 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 HOME		FACILITY NUMBER:	306003067
ADMINISTRATOR:	MARIA I. JIMENEZ		FACILITY TYPE:	740
ADDRESS:	24252 GRASS STREET		TELEPHONE:	(949) 916-2382
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 5	DATE:	01/24/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:48 AM
MET WITH:	Facility Aministrator - Maria Jimenez		TIME COMPLETED:	12:34 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) Celine De Perio conducted an unannounced visit for the Required 1 Year Inspection. LPA was greeted and granted entry by staff on duty. LPA met with facility administrator (AD) Maria Jimenez and explained the purpose of today's visit.

For today’s visit, LPA observed a total of 5 residents in care of which 0 are on hospice and 0 are bedridden and 3 staff members on duty.

LPA observed the Administrator's Certificate for facility administrators Jose Jimenez which expires on 02/22/2024, and Maria Jimenez which expired on 04/20/2021, however, provided proof to LPA that renewal fee, and application was submitted on 01/20/2022, and renewal certificate is pending. The PUB475 "See Something, Say Something" poster was also observed to be posted in the kitchen.

LPA toured the interior and exterior portions of the facility with AD Jimenez. The facility is a two level structure and is licensed for 6 non-ambulatory residents, of which 2 may be on hospice and 0 bedridden. There are a total of 5 bedrooms, of which the 3 downstairs bedrooms are for residents, and the 2 bedrooms located on the upper level, is designated for staff only. LPA observed that there are no residents residing on the upper level of the facility.

LPA toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of 3 restrooms of which 1 is for staff and 2 are for residents. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured to be at 109.9 degrees Fahrenheit.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 HOME	FACILITY NUMBER: 306003067
	VISIT DATE: 01/24/2024

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
26
27
28
29
30
31
32

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguisher was charged, mounted and located in the kitchen.

LPA observed the emergency disaster and evacuation plan, which is posted at the entrance of the facility. Facility had back-up emergency food and water supply, located in the garage. LPA observed that First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to residents in care.

For the exterior portion, LPA observed patio furniture under shading, and the grounds were free of any hazards. LPA De Perio observed that the facility has a pool, and is made inaccessible to residents in care through a locked gate.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

No citations were issued.

An exit interview was conducted with AD Jimenez.

A copy of this report was provided and explained.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2