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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005972
Report Date: 07/24/2026
Date Signed: 07/24/2026 02:47:01 PM

Document Has Been Signed on 07/24/2026 02:47 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:SAINT JOSEPH HOME'S FVFACILITY NUMBER:
306005972
ADMINISTRATOR/
DIRECTOR:		CRUZ, LEAHFACILITY TYPE:
740
ADDRESS:9371 EL VALLE AVETELEPHONE:
(714) 488-8413
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
07/24/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Jilmark M. RealisTIME VISIT/
INSPECTION COMPLETED:
03:00 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) Nancy Guillen made an unannounced visit for the purpose of conducting a required annual Inspection. LPA was greeted and granted entry by care provider after explaining the purpose of the visit. Administrator (AD) Jilmark M. Realis was notified via telephone and later arrived to assist with the inspection. LPA observed the Administrator certificate was current with an expiration date of August 09, 2028. This is a Residential Care Facility for the Elderly (RCFE) licensed to six non-ambulatory residents, of which one may be bedridden, with a hospice waiver for five. The facility is a two-story home with six resident bedrooms, one staff bedroom, six bathrooms, living room, dining room, kitchen and two attached garages. The second floor is made up of one bedroom, one bathroom and a living space designated for staff use only.

During the inspection, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, garage and observed the following:

Continued on LIC 809C

Kevin Saborit-Guasch
Nancy Guillen
DATE: 07/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2026
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 10
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 10
Document Has Been Signed on 07/24/2026 02:47 PM - It Cannot Be Edited


Created By: Nancy Guillen On 07/24/2026 at 01:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in two out of six restrooms, which poses an immediate health, safety or personal rights risk to persons in care. Water temperature tested at 71.2 and 73.2 in two restrooms. The remaining restrooms took about an average of 8 minutes to get hot water.
POC Due Date: 07/25/2026
Plan of Correction
1
2
3
4
Licensee to send an Statement of Understanding to LPA by POC due date via email. Administrator stated there will be repairs done to have the water pressure and the long wait times for hot water mitigated.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above due to cleaning solutions, insecticides, and sharps found throughout the facility and in resident bedrooms which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2026
Plan of Correction
1
2
3
4
Licensee to send an Statement of Understanding to LPA by POC due date via email. In-service training to be sent to LPA by August 14, 2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM MANAGER:
Nancy Guillen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2026


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 07/24/2026 02:47 PM - It Cannot Be Edited


Created By: Nancy Guillen On 07/24/2026 at 01:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above due to carbon monoxide detector being removed which poses/posed a potential health, safety or personal rights risk to persons in care. Carbon Monoxide detector was stored away. AD stated it might have been removed when redecorating which occurred a "few days ago."
POC Due Date: 08/14/2026
Plan of Correction
1
2
3
4
 Carbon Monoxide detector was found and had batteries replaced due to it not functioning when attempting to test the device. Licensee to send a Statement of Understanding for the regulation mentioned above to LPA by POC due date.
Type B
Section Cited
HSC
1569.319(b)
Regulations
(b) A licensee shall ensure the following requirements are met in providing any internet access device for resident use:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above due to the facility not having an internet device for resident use which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2026
Plan of Correction
1
2
3
4
Licensee to provide a device for resident use and send photograph proof to LPA by POC due date via email.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM MANAGER:
Nancy Guillen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2026


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 07/24/2026 02:47 PM - It Cannot Be Edited


Created By: Nancy Guillen On 07/24/2026 at 01:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in one of six resident beds which poses/posed a potential health, safety or personal rights risk to persons in care. Resident 6 is not in hospice and had a full bed rail in place.
POC Due Date: 08/14/2026
Plan of Correction
1
2
3
4
Licensee modified full bed rail to half rail during LPA visit.
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.
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM MANAGER:
Nancy Guillen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2026


LIC809 (FAS) - (06/04)
Page: 5 of 10
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: SAINT JOSEPH HOME'S FV
FACILITY NUMBER: 306005972
VISIT DATE: 07/24/2026
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
LPA observed a residents watching television in the dining room and resting in their respective bedrooms. LPA observed six residents in care and two staff present. LPA observed the See Something Say Something Poster (PUB 475) mounted on the wall by the facility entrance. All resident bedrooms had the required furnishings however, Resident 6 had full bed rails and is not receiving hospice care; a deficiency was cited on today's date. LPA observed all resident beds had linens and blankets with additional linens stored in the garage. LPA observed bathrooms were clean and equipped with grab bars and non skid floor mats. LPA observed all windows were appropriately screened. Bathrooms were observed to be clean, faucets and toilets were operational. Water temperature tested between 71.2 and 115.8 degrees Fahrenheit; a deficiency was cited on today's date. LPA toured the outside of the facility and observed outdoor passageways were free of obstruction. LPA observed the backyard had a shaded sitting area with furniture for resident use.

LPA observed the facility had a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors tested operational. Carbon monoxide detector was non-operational and in a drawer; a deficiency was cited on today's date. Licensee replaced batteries and mounted device on wall by facility entrance. Fire extinguisher was observed to be fully charged with a service date of September 19, 2025 and mounted on the kitchen wall. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable. LPA observed knives and sharps to be stored in a locked kitchen cabinet. The garages are being used for storage. Toxic chemicals, cleaning solutions, and disinfectants were observed to be centrally stored in the garage and under the kitchen sink, however, multiple hazardous items were located throughout the facility including resident rooms; a deficiency was cited on today's date. Medication cabinet was observed to be locked and centrally stored in the dining room closet. LPA observed the facility conducted their last emergency disaster drill on May 26, 2026 and is conducted every 3 months.

During record review. LPA reviewed six resident records. All the required documentation were present and current in the resident files reviewed. LPA reviewed two employee records. All employees present have a criminal record clearance and were associated to the facility. LPA observed records reviewed have a current First Aid certificate.



Based on the observations made during today’s inspection, deficiencies are being cited . An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.
NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Nancy Guillen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026
LIC809 (FAS) - (06/04)
Page: 10 of 10