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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005293
Report Date: 06/14/2024
Date Signed: 06/14/2024 04:59:30 PM


Document Has Been Signed on 06/14/2024 04:59 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:SANDY CREEK CARE HOMEFACILITY NUMBER:
306005293
ADMINISTRATOR:MEJIA, JONALYNFACILITY TYPE:
740
ADDRESS:26442 SANDY CREEKTELEPHONE:
(949) 273-3799
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 5DATE:
06/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Jonalyn MejiaTIME COMPLETED:
05:15 PM
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The Licensing Program Analyst (LPA Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Administrator Jonalyn Mejia and explained the reason for the visit. The Administrator's certificate expires on December 6, 2024. LPA and the Administrator toured the facility. The last fire drill was conducted on April 2, 2024, Smoke detectors and the carbon monoxide detectors tested operational. The facility is a single story home with 5 bedrooms, 2 bathrooms, living room with a screened fireplace, dining room, kitchen and an attached two car garage. LPA observed the see something say something sign is posted in the hallway and measures 8 1/2 by 11 inches. LPA observed the garage is used for storage of supplies and old furniture. LPA observed the kitchen is clean and organized. The knives and sharp objects are kept locked in a kitchen drawer. Cleaning supplies are kept locked under the sink. LPA observed a two day perishable and a seven day non-perishable food supply on hand in the kitchen. The fire extinguisher in the kitchen is fully charged. The facility has 5 bedrooms, 4 are for residents and one bedroom is for staff. LPA observed all resident rooms had the required furniture and bed linens. Extra linens are stored in the hall closet. LPA observed both bathrooms are clean and operational. Hot water measured 109.0 degrees Fahrenheit in both bathrooms. No obstacles or hazards observed inside the facility. LPA and Administrator toured the backyard. No bodies of water observed. There is a shaded seating area for residents to sit outside. The exit gate is operational and is self closing. No obstacles or hazards observed in the backyard. LPA reviewed 6 out of 6 resident records, no discrepancies observed. LPA reviewed 6 out of 6 resident medications, no discrepancies observed. LPA reviewed 4 staff files, no discrepancies observed. LPA inspected the first aid kit. The first aid kit has all the required elements. LPA consulted with Administrator concerning reporting requirements.

No deficiencies observed during the visit. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024
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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