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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005808
Report Date: 07/22/2021
Date Signed: 07/22/2021 12:58:32 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: 3DATE:
07/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:29 AM
MET WITH:Administrators, Leah Cruz and Miguelito FajardoTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted, granted entry into the facility and temperature checked by Caregiver. LPA explained reason for the visit.

During the visit LPA toured the facility with Caregiver. During the visit, Administrators Leah Cruz and Miguelito Fajardo arrived at facility. Facility is a 6 bedroom,( 5 resident bedrooms 1 staff bedroom) and 2 bathroom single story home. There are 3 Residents in care. LPA observed proper covid signage at front entrance of facility as well as sign in, sanitization and temperature check station. Facility has required Department postings. LPA observed copy of Administrators Certificate expiring March 10, 2023. LPA toured all Residents rooms, all rooms where within regulations. All restrooms observed contained soap, toilet paper, paper towels and hand sanitizer. Restrooms had proper hand washing signs posted. Residents were observed relaxing eating in dining room and in bedrooms. Facility has operating smoke detectors and audible alarms for each sliding door entrance/exit. Facility has 2 fire extinguishers which are fully charged. Facility has supply of PPE. Facility has 2 refrigerators with food supply. LPA observed facility has emergency food and water supply. Facility has required Emergency Disaster Plan posted. Facility has a secured location for resident medication and files. Facility has 30 days supply of medications for residents. LPA reviewed residents files during visit. Residents emergency contact information and Physicians reports are current. Facility has a designated visitation area.

No deficiencies noted during todays visit. An exit interview was conducted with Administrators and a copy of report was left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
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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