306006303-1-27-2025-22-AS-BLOZ-DDC2SM-20250127163924

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006303
Report Date: 01/27/2025
Date Signed: 01/27/2025 04:39:33 PM

Document Has Been Signed on 01/27/2025 04:39 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	CARE SAINT JACOB		FACILITY NUMBER:	306006303
ADMINISTRATOR/ DIRECTOR:	JULIE G CORNEJO		FACILITY TYPE:	740
ADDRESS:	4110 E JORDAN AVE		TELEPHONE:	(714) 289-1946
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	01/27/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:35 PM
MET WITH:	Administrator Julie Cornejo		TIME VISIT/ INSPECTION COMPLETED:	04:55 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) Brandon Lopez made an unannounced visit for the purpose of conducting the required annual inspection. LPA was greeted and granted entry by caregiver staff after explaining the purpose for the visit. Administrator (AD) Julie Cornejo was notified via telephone and later arrived to assist with the inspection. LPA observed that Administrator Julie Cornejo has a valid Administrator certificate which expires on June 3, 2026. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents, of which one may be bedridden, with a hospice waiver for six. The facility is a single story home with six private resident bedrooms, one staff room, three resident bathrooms, two of which are shared, a living room, a dining room, a kitchen, a laundry room, and an attached two car garage. LPA accompanied by the AD conducted a tour of the physical plant. On today's visit, LPA observed six residents in care and three caregiver staff present. LPA observed residents relaxing in their respective bedrooms. LPA observed the See Something, Say Something poster (PUB 475) mounted on a wall by the entryway of the facility. LPA inspected all six resident bedrooms, and they were observed to be free of any hazards. LPA observed the resident bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. All resident beds had clean linens and blankets. LPA observed additional linens are stored in a hallway closet. LPA inspected the three resident bathrooms. Resident bathrooms are clean. Bathrooms are equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 108.6 and 114.6 degrees Fahrenheit. LPA observed the staff room is kept locked and inaccessible to residents in care. LPA observed the kitchen has a two day perishable and seven day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. The five burner gas stove lights unassisted. LPA observed kitchen knives are stored in a locked kitchen cabinet. LPA observed chemicals and toxins to be stored in a locked kitchen cabinet under the sink. CONTINUED ON LIC809-C

Sheila Santos	TELEPHONE: (714) 703-2857
Brandon Lopez	TELEPHONE: (714) 483-4521
	DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CARE SAINT JACOB	FACILITY NUMBER: 306006303
	VISIT DATE: 01/27/2025

NARRATIVE

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A fire extinguisher is located in the kitchen and in the laundry room. Fire extinguishers were observed the be charged and serviced as of September 26, 2024. LPA tested the wired smoke detectors/carbon monoxide detectors which tested operational. LPA observed the facility conducted their last emergency disaster drill on October 23, 2024. The centrally stored medication is kept in a locked closet in the resident hallway. LPA observed Personal Protective Equipment and a First Aid Kit to be stored in the closet in the resident hallway. LPA observed the First Aid Kit has all the required components. Chemicals and toxins were observed to be stored in a locked cabinet in the laundry room. The door leading to the attached two car garage is kept locked and inaccessible to resident. The garage is used for storage and laundry. LPA observed chemicals to be stored in the locked two car garage. LPA observed the facility has a three day emergency food and water supply stored in the garage.

LPA and AD conducted a tour of the exterior portion of the facility. LPA observed the exterior portion to be clear of obstructions and hazards. LPA observed a shaded outdoor seating area with furniture for resident use. The perimeter gate on the west side of the facility is self-latching and can be opened in an evacuation. There are no bodies of water on the premises.

LPA reviewed all six resident files. LPA observed that the Reappraisals for Resident #1, Resident #2, Resident #3, and Resident #6 were outdated. LPA observed that Resident #5 did not have a Reappraisal on file. LPA observed that Resident #2 did not have an Admission Agreement on file. LPA reviewed six residents’ medication and medication records. LPA reviewed four staff files. All staff are background cleared and associated to the facility.

Based on today's observations, deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Julie Cornejo. A copy of the report and Appeal Rights were provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Brandon Lopez	TELEPHONE: (714) 483-4521
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/27/2025 04:39 PM - It Cannot Be Edited

Created By: Brandon Lopez On 01/27/2025 at 04:25 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: CARE SAINT JACOB	FACILITY NUMBER: 306006303
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(a)

Reappraisals

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. Based on file review, LPA observed that four out the six resident's had a Reappraisals that were outdated. LPA also observed that Resident #5 (R5) did not have a Reappraisal on file.
	POC Due Date: 02/10/2025
	Plan of Correction
1 2 3 4	AD agreed to complete a Reappraisal for Resident #1. Resident #2, Resident #3, Resident #5, and Resident #6. AD agreed to provide proof of completion to LPA by POC date via email or fax.

Type B

Section Cited

CCR

87507(c)

Admission Agreements

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. During file review, LPA observed that Resident #2 (R2) did not have a signed Admission Agreement on file. LPA observed that the Admission agreement was not signed by the resident/resident's representative or a facility representative.
	POC Due Date: 02/10/2025
	Plan of Correction
1 2 3 4	AD agreed to complete an Admission Agreement for Resident #2. AD agreed to provide proof of a completed Admission Agreement to LPA by POC date via email or fax.

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:

Sheila Santos

TELEPHONE: (714) 703-2857

LICENSING EVALUATOR NAME:

Brandon Lopez

TELEPHONE: (714) 483-4521

LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC809 (FAS) - (06/04)

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