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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005808
Report Date: 06/07/2022
Date Signed: 06/07/2022 02:39:12 PM


Document Has Been Signed on 06/07/2022 02:39 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: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: 6DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:11 PM
MET WITH:Miguelito FajardoTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced annual inspection focusing primarily on the Infection Control. LPA was greeted and granted entry by Caregiver Winnie Inoncillo and Administrator (Admin) Miguelito Fajardo. LPA stated the purpose of the visit and entered the facility after completing the Coronavirus 2019 (COVID-19) screening procedure. Upon entry, LPA observed the screening station and sign in sheet with temperatures of visitors documented daily. The required Department COVID-19 precautionary signs were posted on the front door and in the entry way. The Administrator's Certificate for Leah Ann R Cruz expires on 3/10/2023.

Around 1:25 pm, LPA and Admin toured the interior and exterior portions of the facility. The facility is a single level structure and licensed for six non-ambulatory of which one may be bedridden in Bedroom #1; and has a hospice waiver for four residents. As of today, facility had six residents of which 3 are in hospice care. Three residents were watching television in the living room and the remaining three residents were napping in their respective bedrooms. Facility appeared clean and sanitary in all observed areas. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke, carbon monoxide, and auditory exit alarms tested operational. Bathrooms observed to be in good repair; and provided with a grab bar and a non-skid floor mat. Facility had the required hand washing signs posted in all the bathrooms. Hot water measured at 118.0 degrees Fahrenheit in Bathroom #1 and 117.3 degrees Fahrenheit in Bathroom #2. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies, and sharp items were inaccessible to the residents in care. The fire extinguisher was mounted and charged in the kitchen. For the exterior portion, the facility had patio furniture under ample shading, and grounds were free of tripping hazards. The side gate was self-closing and self-latching. LPA observed the emergency disaster and evacuation plans. Facility had sufficient emergency food and water supply. The First Aid Kit had all the required components, and the facility had sufficient PPE supplies stored in the garage.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022
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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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: 06/07/2022
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LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to 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. Staff's smart phone is available to use upon the resident's request.

LPA Cho reviewed the COVID 19 mitigation plan of the facility. No deficiency cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit, and the licensee will follow-up with the corrections An exit interview was conducted with Administrator Miguelito Fajardo, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC809 (FAS) - (06/04)
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