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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003067
Report Date: 02/06/2025
Date Signed: 02/06/2025 12:44:22 PM

Document Has Been Signed on 02/06/2025 12:44 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 HOMEFACILITY NUMBER:
306003067
ADMINISTRATOR/
DIRECTOR:
MARIA I. JIMENEZFACILITY TYPE:
740
ADDRESS:24252 GRASS STREETTELEPHONE:
(949) 916-2382
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
02/06/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Caregiver Rosa HernandezTIME VISIT/
INSPECTION COMPLETED:
12:59 PM
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Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility for the purpose of following up on a plan of correction for a deficiency cited during the annual visit conducted on 1/15/2025. LPA was greeted and granted entry by care giving staff and explained the purpose of the visit. Administrator (AD) Maria Jimenez was notified via telephone but was not available to assist with the inspection.

During the annual inspection completed on 1/15/2025, LPA observed a pipe, construction materials, and two buckets left unattended by the outdoor covered patio. LPA observed a ladder left unattended by the shed. LPA also observed boxes of trash, a vacuum, a bucket, and concrete blocks on the side south of the exterior portion of the facility.

On today’s visit, LPA observed that the pipe, the construction materials, and the two buckets that were observed by the outdoor covered patio had been removed. LPA observed that the ladder had been removed and is now stored in the locked two car garage. LPA observed that the boxes of trash, the vacuum, the bucket, and the concrete blocks that were observed on the side south of the facility had been removed. LPA observed that all obstructions and hazards that were observed on the annual inspection completed on 1/15/2025 have been removed.

The plan of correction for the deficiency was cleared during today's visit. An exit interview was conducted with Caregiver staff Rosa Hernandez. Administrator Maria Jimenez notified LPA via telephone that Caregiver staff Rosa Hernandez was authorized to sign the report. A copy of this report, along with the plan of correction clearance letter was provided.
Sheila SantosTELEPHONE: (714) 703-2857
Brandon LopezTELEPHONE: (714) 483-4521
DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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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