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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001399
Report Date: 02/24/2025
Date Signed: 02/24/2025 12:29:44 PM

Document Has Been Signed on 02/24/2025 12:29 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:SADDLEBACK F.M.J. ELDERLY CARE HOMEFACILITY NUMBER:
306001399
ADMINISTRATOR/
DIRECTOR:		JIMENEZ, MARIAFACILITY TYPE:
740
ADDRESS:25482 MAXIMUSTELEPHONE:
(949) 380-0797
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
02/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Maria JimenezTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by Administrator (AD) Maria Jimenez and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents, with a hospice waiver for two. Currently there are six residents, of which there are none on hospice during today's visit.

At around 9:20 AM, LPA Tea reviewed six resident files and two staff files. There were discrepancies noted in the review of resident and staff files. Administrator certificate expires on April 20, 2025. Last facility disaster drill was conducted on February 20, 2025.



LPA Tea along with caregiver toured the facility around 10:25 AM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a single-story home that consists of 3 resident bedrooms, 3 staff rooms, 3 bathrooms, living room, dining room, kitchen, family room, laundry area and attached garage. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms, and they are operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 107.9 degrees F and 113.3 degrees F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. There are cameras with no audio in the common areas to monitor the safety of the residents. The house is currently going under some small renovations where they are rewiring the wires and cords going throughout the facility. The walls will be patched up and repainted once they finish with the minor repairs. First aid kit had all the required elements including bandages, dressings, tweezers, thermometer, and scissors. Kitchen was inspected. Kitchen appliances are operational during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps

Annual continuation on LIC809-C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2025
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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Document Has Been Signed on 02/24/2025 12:29 PM - It Cannot Be Edited


Created By: Michael Tea On 02/24/2025 at 11:47 AM
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: SADDLEBACK F.M.J. ELDERLY CARE HOME
FACILITY NUMBER: 306001399

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's review of staff records there were no recent staff training conducted. The last records show there were staff training from 2023. This poses as a potential health and safety risk to residents in care.
POC Due Date: 03/17/2025
Plan of Correction
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Licensee will conduct staff training and provide proof by POC due date to LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Michael Tea
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2025


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: SADDLEBACK F.M.J. ELDERLY CARE HOME
FACILITY NUMBER: 306001399
VISIT DATE: 02/24/2025
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locked in the closet with medication. LPA also observed toxin substances to be locked and inaccessible to clients in care underneath the sink and secured in the garage. The fire extinguishers throughout the facility were fully charged. LPA toured the outside grounds and there is ample seating with shade and two exit gates on both sides of the facility are self-latching and operational. There is a pool in the backyard with a secured fence around it. LPA observed emergency supplies, food, and water supply in the garage. Facility provides activities based on resident interests. Residents go out for walks; they listen and dance to music. Staff sometimes do their nails. There is someone that comes on Thursday to conduct activities with the residents like exercises. At the time of annual visit, residents were seen watching television and having lunch later during the visit.

Around 10:54 AM, LPA reviewed medication storage and administration. Medications are stored in a locked cabinet. Medications are being administered per physician order. LPAs interviewed residents regarding their quality of care and spoke to staff present regarding care provided.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Administrator Maria Jimenez and a copy of these reports were given to the facility along with a copy of the LIC 858; 859;809-D, and Appeal Rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
LIC809 (FAS) - (06/04)
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