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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003472
Report Date: 11/18/2022
Date Signed: 11/18/2022 02:17:43 PM

Document Has Been Signed on 11/18/2022 02:17 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: 6DATE:
11/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:31 PM
MET WITH:House Manager-Yaarah CruzTIME COMPLETED:
02:37 PM
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio explained reason for visit and was greeted and granted entry by staff on duty who checked temperature prior to entering facility. During the visit, 1 staff was on duty, who contacted house manager (HM) Yaarah Cruz about visit. As of 11/18/22, there are 0 active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted throughout the facility. LPA De Perio observed the Administrator's Certificate for Carmen Cruz, which expired on 10/12/22, however LPA De Perio was provided documentation that renewal fee was submitted on 9/30/22.

LPA De Perio toured the interior and exterior portions of the facility with HM Cruz The facility is a two level structure and is licensed for 6 ambulatory clients ranging from the ages of 18-59 years old. Currently, there are a total of 6 clients in care. For this visit, only 1 client was present at facility, while the remaining 5 clients were attending Day Program. Facility has a total of 8 bedrooms. On the first floor, there are a total of 6 bedrooms of which 4 are private client rooms, 1 shared room for clients and 1 for staff. On the second floor, there are a total of 2 bedrooms, of which 1 is designated for staff, and 1 is utilized as an isolation room (for COVID). LPA De Perio observed and verified that there are no clients residing on the second floor. All 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. The restrooms were observed to be in good repair, and toilets were operational. Water temperature in restrooms were measured at 107.8 degrees Fahrenheit and hand washing signs were also posted in each restroom.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2022
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 4
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: CRUZ HOUSE, THE
FACILITY NUMBER: 306003472
VISIT DATE: 11/18/2022
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Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to clients in care and located in a locked kitchen drawer. Fire extinguisher was charged, and located in the kitchen. LPA De Perio observed the emergency disaster and evacuation plan, which is posted in the kitchen. Facility had back-up emergency food and water supply, located in the garage.

For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There is one exit gate in the backyard, which was self-closing and self-latching. There is a locked shed in the backyard, which is utilized for storage. No bodies of water were observed.

LPA De Perio observed that First Aid Kit had all the required components. The facility had an adequate supply of PPE that was located in the garage. Medications were locked in a hallway cabinet and inaccessible to clients in care. Toxins were also observed to be locked and inaccessible to clients and located in the garage.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with HM Cruz. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

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

LPA De Perio discussed with HM Cruz to review, and subscribe for emails regarding the Provider Information Notices (PINs) as well as to attend the CCLD Informational Calls to ensure that facility and staff are up to date. The PINs can be accessed at: www.ccld.ca.gov.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: CRUZ HOUSE, THE
FACILITY NUMBER: 306003472
VISIT DATE: 11/18/2022
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LPA De Perio discussed the California Code of Regulations Section 85075.4 Observation of the Client and Sections 80061 and 85061 Reporting Requirements with HM Cruz.

LPA De Perio advised HM Cruz to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

LPA De Perio conducted an exit interview with HM Cruz and a copy of this report, and copies of the regulations discussed were provided to the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
LIC809 (FAS) - (06/04)
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