306005972-7-11-2022-22-AS-RQUZ-CG8VNP-20220711163527

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005972
Report Date: 07/11/2022
Date Signed: 07/11/2022 04:36:10 PM

Document Has Been Signed on 07/11/2022 04:36 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:	SAINT JOSEPH HOME'S FV		FACILITY NUMBER:	306005972
ADMINISTRATOR:	CRUZ, LEAH		FACILITY TYPE:	740
ADDRESS:	9371 EL VALLE AVE		TELEPHONE:	(714) 488-8413
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	6	CENSUS: 6	DATE:	07/11/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:58 PM
MET WITH:	John Jason Eugenio, Assistant Administrator		TIME COMPLETED:	04:51 PM

NARRATIVE

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On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Quiroz was greeted and granted entry into the facility by Caregiver (CG) Ted Nichols Abapo and met with Assistant Administrator (AA) John Jason Eugenio and explained the nature of the visit. Facility indicated screening all incoming visitors prior to entering the facility. Facility is licensed to provide services to Age range 60 and over, 6 Non Ambulatory residents of which (1) one may be bedridden, and has a Hospice Waiver for (5) five residents. Facility currently providing services to three (3) residents on hospice. Administrator Brian Estorba has a current Administrator certificate with expiration date of October 12, 2023.

On or about 3:37pm, LPA Rosie Quiroz along with (AA) John Jason Eugenio began the tour of the inside and outside of the facility. There are six (6) residents in care and there are no active COVID-19 cases in the facility. LPA Quiroz observed two of six residents in the living-room area resting supervised by caregivers, and four of six residents observed to be resting and watching television in their private bedrooms. LPA Quiroz interacted and interviewed with resident's during today's visit. Six of six residents appeared to be clean and well taken care of. LPA Quiroz observed a COVID-19 check in station in the entry of the facility; LPA Quiroz observed required department COVID-19 precautionary postings in the facility as well as hand washing signs throughout the facility. Facility temperature recorded to be 72 degrees fahrenheit.

All restrooms observed to have a supply of soap, appeared to be clean and water temperatures were recorded to be within 79-84 degrees Fahrenheit. LPA Quiroz inspected resident’s bedrooms and appeared to be clean. All bedrooms observed to have all required components. LPA Quiroz observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food, water and PPE in garage area readily available for staff and residents. LPA Quiroz toured the outside of the facility and observed seating and shaded area for residents and visitor's enjoyment in backyard area.

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SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022

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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Document Has Been Signed on 07/11/2022 04:36 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SAINT JOSEPH HOME'S FV	FACILITY NUMBER: 306005972
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

This requirement is not met as evidenced by:On today's date at 4:01pm while conducting physical plant inspection, LPA Quiroz recorded water temperatures to be recorded between 79-84 degrees Fahrenheit. This was verified with Assistant Administrator John Jason Eugenio who indicated "Yes, we have already called the plumber but the plumber had covid and won't be here until end of the week."
	Deficient Practice Statement
1 2 3 4	Based on LPA Quiroz's observation and interviews conducted today, the licensee did not comply with the section cited above which poses an immediate health risk to persons in care.
	POC Due Date: 07/15/2022
	Plan of Correction
1 2 3 4	Licensee will call and schedule plumber repair by July 15, 2022 and submit proof of repair to CCL by July 15, 2022.

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: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022

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: SAINT JOSEPH HOME'S FV	FACILITY NUMBER: 306005972
	VISIT DATE: 07/11/2022

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The facility has completed the LIC 808 Mitigation Plan. The LIC 808 plan was received by the Department on January 20, 2021. During today's visit, LPA Quiroz reviewed and approved LIC 808 Mitigation Plan dated January 20, 2021.

LPA Quiroz was informed that all residents and staff have had their COVID-19 vaccinations and first Booster and coordinating with resident's families about second booster vaccination. Facility indicated to be recording resident's temperatures daily.

During today's visit, LPA Quiroz provided Consultation on Title 22 and COVID-19 Infection control throughout today's visit.

Based on the observation made during today’s visit, deficiency was noted today per Title 22 Division 6 of the California Code of Regulations. (SEE LIC 809-D)

This report was reviewed with (AA) John Jason Eugenio, and a copy of this report, Appeal Rights and LIC 811 Confidential Names were provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022

LIC809 (FAS) - (06/04)

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