306003472-12-31-2024-22-AS-KSGH-DCGV39-20241231150423

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003472
Report Date: 12/31/2024
Date Signed: 12/31/2024 03:05:08 PM

Document Has Been Signed on 12/31/2024 03:05 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:	CRUZ HOUSE, THE		FACILITY NUMBER:	306003472
ADMINISTRATOR/ DIRECTOR:	CRUZ, CARMEN N. & OMAR		FACILITY TYPE:	735
ADDRESS:	24252 FORDVIEW STREET		TELEPHONE:	(949) 581-8526
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY: 6		CENSUS: 5	DATE:	12/31/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:40 PM
MET WITH:	Yaaran Cruz, administrator		TIME VISIT/ INSPECTION COMPLETED:	03:15 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 Analysts (LPA) Kevin Saborit-Guasch conducted an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the purpose of the visit. Administrator Yaarah Cruz was notified by telephone and arrived later to assist with the visit. The facility is an Adult Residential Facility licensed for six ambulatory clients. There are currently five clients in care, two of which are physically present at the facility. Both clients are observed relaxing in their bedrooms or in the facility's common areas. The facility is a two-story home. Clients occupy five individual bathrooms on the facility's ground level. Clients share two bathrooms on the ground level. The upper level is for use by staff and their family only as verified during the visit. Upper level includes two additional bedrooms and a bathroom. The facility's interior appears clean, safe, and sanitary. All clients’ rooms had required elements, including bed, chair, closet space, and ample lighting. Hot water measured at 107F. LPAs observed the facility had a two-day supply of perishables and a seven-day supply of non-perishable food available as required by regulations. LPAs observed hallways and walkways were free of obstructions. There are no bodies of water on the premises. The backyard is observed to have outdoor furniture and a shaded area that can be used by the clients. The route of egress is free of obstructions and all tools and potentially dangerous items are secured from being accessed by the clients in care. CONTINUED ON FORM LIC809-C

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024

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 3

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: CRUZ HOUSE, THE	FACILITY NUMBER: 306003472
	VISIT DATE: 12/31/2024

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

CONTINUED FROM LIC809
LPA observed a fire extinguisher present in the dining room. It is charged and has been maintained on December 30, 2024. Staff and LPA tested smoke and carbon monoxide detectors which were found to be operational. Sharp instruments are stored in a locked drawer in the kitchen. Cleaning supplies and laundry area and products are stored in the locked garage. Medication for each client is kept locked and secured in a locked cabinet in the kitchen.

LPA reviewed all five clients’ files and medications as well as P&I records for the two clients present. They were verified to correspond to the amount noted on the ledgers. Receipts also match the amounts and dates logged in the ledger. LPA reviewed three staff files. All current staff members are cleared and associated.

The Emergency and Disaster Plan was reviewed along with documentation of fire and emergency drills conducted quarterly. The facility follows infection control and surface/hand washing precautions however it does not have an Infection Control Plan in place. Technical Violation Advisory Note provided along with a copy of the current LIC9282 form.

No deficiencies are cited during today's inspection visit. Two consultations were provided on Technical Violation Advisory Notes regarding the Infection Control Plan. An exit interview was conducted and a copy of this report was provided to the facility staff.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3