306005808-7-29-2024-22-AS-JCHO-D7MURE-20240729154838

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005808
Report Date: 07/29/2024
Date Signed: 07/29/2024 03:48:43 PM

Document Has Been Signed on 07/29/2024 03:48 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:	ST. JOSEPH'S HOME		FACILITY NUMBER:	306005808
ADMINISTRATOR:	FAJARDO, MIGUELITO		FACILITY TYPE:	740
ADDRESS:	24671 ELOISA DRIVE		TELEPHONE:	(949) 305-1175
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 5	DATE:	07/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Miguelito Fajardo, Leah Ann Fajardo- Administrators		TIME COMPLETED:	04:00 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) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual inspection using the CARE Tool. LPA was greeted and granted entry by Caregiver Jocelyn Regalado. Administrators (Admins) Miguelito and Leah Ann Fajardo arrived on premise approximately 2:00pm. During today's visit, LPA observed five residents in care and two caregivers on duty. LPA observed the facility to be clean and sanitary. There are five resident bedrooms and two resident bathrooms. All common areas were inspected including the attached two car garage which doubled as a laundry room. The residents' bedrooms were appropriately furnished. Beds and bedding supplies were in good condition, adequate lighting was provided, sufficient storage space for each residents' personal belongings were observed. Bathrooms were found to be in compliance, clean, and operational. The water temperature measured at 114.8 and 125.0 degrees Fahrenheit. LPA observed the indoor temperature was within a comfortable range. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed sufficient two-day supply of perishables and seven-day supply of non-perishable food available. LPA toured the exterior portion of the facility. LPA observed the outdoor passageway free of obstruction. The exit gate was in good repair. LPA observed sufficient seating and shading. Facility maintains fire extinguishers which were observed to be mounted, charged, and serviced on May 28, 2024. The auditory devices and smoke/carbon monoxide detectors were tested and operational. Emergency disaster supplies including food/water were present. Emergency evacuation drills were not conducted on a quarterly basis with the last drill approximately 2021. The first aid kit contains all necessary elements.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

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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Document Has Been Signed on 07/29/2024 03:48 PM - It Cannot Be Edited

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: ST. JOSEPH'S HOME	FACILITY NUMBER: 306005808
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(3)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, one out of the two bathrooms measured above 120 degrees which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
	POC Due Date: 07/30/2024
	Plan of Correction
1 2 3 4	Adminstrator will provide the correction to LPA via email by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: ST. JOSEPH'S HOME	FACILITY NUMBER: 306005808
	VISIT DATE: 07/29/2024

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LPA observed the required 'See Something, Say Something' (PUB475) poster in the correct size. The Administrator's Certificate for Leah Ann Fajardo expires on March 10, 2025.

LPA conducted an audit of five residents' files and two personnel files. No discrepancies noted. Residents/staff interviews were conducted and medications were audited. No discrepancies noted.

Based on the observations made during today's visit, one deficiency is being cited. An Advisory Note is also issued.

An exit interview was conducted with Administrators Miguelito and Leah Ann Fajardo, and a copy of this report, and the appeal rights were provided at the end of the visit.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC809 (FAS) - (06/04)

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