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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003472
Report Date: 12/20/2021
Date Signed: 12/20/2021 02:09:07 PM

Document Has Been Signed on 12/20/2021 02:09 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:CRUZ HOUSE, THEFACILITY NUMBER:
306003472
ADMINISTRATOR:CRUZ, CARMEN N. & OMARFACILITY TYPE:
735
ADDRESS:24252 FORDVIEW STREETTELEPHONE:
(949) 581-8526
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: DATE:
12/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:03 PM
MET WITH:Leovanis CruzTIME COMPLETED:
02:25 PM
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Licensing Programs Analysts (LPAs) Ruth Martinez and Kevin Saborit-Gausch conducted an unannounced visit for the purpose of conducting a required annual inspection. LPAs were greeted and granted entry into the facility by staff. LPAs met with Leovanis Cruz, Administrator and explained the nature of the visit.

LPAs accompanied by Administrator began the tour of the inside and outside of the facility. There are six clients in care and there are no active covid-19 cases in facility. LPAs observed required department postings, covid-19 precautionary postings in the facility as well as hand washing signs throughout the facility. All restrooms observed to have ample supply of soap/sanitizer and appeared to be clean. LPAs inspected client’s bedrooms and appeared to be clean and sanitary. All bedrooms observed to have all required components. LPA observed a check in station in the main entry of the facility. Facility is taking temperature daily and documenting the results. LPAs observed the emergency disaster and evacuation plan. Facility has an emergency food and water supply as well as PPE supplies in the attached garage. Facility has a second floor and there are no clients residing on the second floor. Second floor is inaccessible to clients. LPAs toured the outside of the facility and observed a shaded seating area for clients enjoyment. The facility has completed the LIC808 Mitigation Plan, the plan was approved by the department on March 12, 2021. LPAs were informed that staff and residents are scheduled to get their covid booster shot.

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the Administrator and a copy of this report was provided to the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2021
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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