<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005808
Report Date: 06/26/2020
Date Signed: 06/26/2020 03:41:04 PM

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:ST JOSEPH'S HOMEFACILITY NUMBER:
306005808
ADMINISTRATOR:FAJARDO, MIGUELITOFACILITY TYPE:
740
ADDRESS:24671 ELOISA DRIVETELEPHONE:
(949) 305-1175
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
06/26/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Miguelito "Bing" Fajardo, AdministratorTIME COMPLETED:
03:25 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 Analyst (LPA) Tricia Danielson contacted the facility via telephone to conduct a Prelicensing inspection via Facetime with Administrator (AD) Miguelito "Bing" Fajardo. An initial application to operate a Residential Care For the Elderly facility (RCFE) was submitted to the Central Applications Unit (CAU) on 02/25/2020 for a total capacity of six (6) non-ambulatory residents, one (1) of which may be bedridden. Fire Clearance was granted on 06/09/2020 for six (6) non-ambulatory residents, one (1) which may be bedridden. Component III was completed during this visit. LPA Danielson observed the following:
Structure:
Facility was a one story house with five (5) resident bedrooms and one (1) caregiver bedroom, two (2) bathrooms, living room, dining area and kitchen. There was an attached two (2) car garage.
Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located in the hallway to control entire house.
Bedrooms:
Each resident bedroom will accommodate any non-ambulatory resident. All resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operational smoke alarm. Bedroom #6 is identified as the bedridden room and was verified to have the appropriate exit requirements. There was one (1) caregiver bedroom for live-in staffing.
Bathrooms:
Two (2) of (2) resident bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, paper towels and toilet paper. At 2:20 PM, AD began testing water temperatures in both resident bathrooms. Temperature readings were verified by LPA. Water temperatures measured between 115.3 and 116.7 degrees Fahrenheit.
Kitchen/Dining:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments
(CONTINUED ON LIC 809 C)
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (626) 423-4825
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2020
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 2
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: ST JOSEPH'S HOME
FACILITY NUMBER: 306005808
VISIT DATE: 06/26/2020
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 LIC 809)
were secured in a locked cabinet and drawer. There was adequate room for food storage. Refrigerator/freezer were in working condition and had sufficient supply of perishable food. LPA observed the stove to be operational. There was adequate seating for meals for all residents. Sample menu was posted in the kitchen.
Living/Family room:
There was a living area with safe and adequate seating for all residents as well as working TV.
Linens and Hygiene Supplies:
An adequate supply of linens and toiletries were stored in a closet in the main hallway.
Yards/Outside:
There was a patio with adequate covered seating for all residents. Fencing secured the entire backyard. There was a front yard and an operational self-latching gate on the right side of the facility which lead to the backyard. All outdoor pathways were free of obstructions. There were no bodies of water observed anywhere on the property.
Garage/Laundry:
There was a washer and dryer located in a room just off the kitchen. Laundry detergents and cleaning solutions were secured and inaccessible to residents. 72 hour emergency supplies and water were also observed in storage bins located in the garage and laundry room. Garage was organized and free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Let-Us-No poster, Ombudsman poster, and AD certificate were posted near the entry way. Emergency phone numbers were posted in the kitchen. Facility exit plan was posted near the front door.
General items:
One (1) fire extinguisher was charged and mounted in the kitchen and and an additional charged fire extinguisher is kept in the caregiver's bedroom. Smoke alarms and the carbon monoxide detector were tested and found to be in working order. Emergency lighting flashlights were tested and found to be operational. Resident records and staff files were stored in the front closet. A complete First Aid kit and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational utilizing LPA cellphone. Prelicensing is complete and this facility has no deficiencies. The license will be granted based on final review by and approval from the Central Applications Unit. An exit interview was conducted with AD Fajardo via telephone and a copy of this report was provided via email and a read receipt confirms the facility has received the report.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (626) 423-4825
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2020
LIC809 (FAS) - (06/04)
Page: 2 of 2