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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003067
Report Date: 01/27/2026
Date Signed: 01/27/2026 04:51:44 PM

Document Has Been Signed on 01/27/2026 04:51 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 FMJ III ELDERLY CARE HOMEFACILITY NUMBER:
306003067
ADMINISTRATOR/
DIRECTOR:		MARIA I. JIMENEZFACILITY TYPE:
740
ADDRESS:24252 GRASS STREETTELEPHONE:
(949) 916-2382
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 6DATE:
01/27/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Maria Jiminez (Administrator)TIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
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On today's date January 27, 2026 Licensing Program Analyst (LPA) Brandon William Vanegas made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by caregiver staff and explained the purpose for the visit. Administrator (AD) Maria Jimenez was notified via telephone and later arrived to assist with the inspection. LPA observed that Administrator Maria Jimenez has a valid Administrator certificate which expires on April 20, 2027.

LPA Vanegas began a tour of the facility and observed the following, the facility is a two story home, and consists of six bedrooms three of which are resident bedrooms, and three of which are staff bedrooms, two resident bathrooms, a living room, a dining room, a kitchen, and an attached two car garage. The upstairs portion of the facility is designated for staff only. LPA accompanied by the AD conducted a tour of the physical plant. On today's visit, LPA observed six residents in care and two caregiver staff present. LPA observed the See Something, Say Something poster (PUB 475) mounted on a wall by the kitchen. The PUB 475 poster measured 20X26. LPA inspected the three resident bedrooms and they were observed to be free of any hazards. LPA observed the resident bedrooms had the required furnishings such as a bed with clean linens in good repair; meaning no strains or tares, a chair, a chest of drawers, a reading lamp, and enough storage space to store personal belongings. LPA observed additional linens are stored in a hallway closet.

LPA inspected the two shared bathrooms. Resident bathrooms are clean and free of mildew and debris. Bathrooms are equipped with grab bars and slip resistant floor mats. Water faucets and toilets tested operational. Hot water temperature measured between 110.3 and 116.4 degrees Fahrenheit. LPA inspected the staff bedroom which was observed to be locked. CONTINUED ON LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2026
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 4
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)
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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 FMJ III ELDERLY CARE HOME
FACILITY NUMBER: 306003067
VISIT DATE: 01/27/2026
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LPA Vanegas observed kitchen area to be clean and free of any mildew and debris. LPA observed a gas stove, microwave, refrigerator, dishwasher, washer, and dryer to all be in good repair, and tested operational. LPA Vanegas observed refrigerator to be at the appropriate temperature, and have a two day supply of perishable food and a seven day supply of non-perishable food.

LPA Vanegas observed fire extinguisher in the kitchen area to be fully charged and recently purchased with receipt attached to it with a purchase date of November 25, 2025. LPA observed all smoke and carbon monoxide detectors to be operational. LPA Vanegas observed first aid kit to have all required items such as a thermometer, bandages, adhesive tape, scissors, tweezers, and a first aid manual.

LPA reviewed six resident files, all six files were missing a weight record. Per LPA review of facility staff records three staff members had an expired CPR/First aid certification deficiencies were issued on today's date. taff had required annual training up to date and documents. LPA reviewed medication administration log and medications accompanied by AD, per LPA review all medications are being administered per physicians orders.

LPA Vanegas conducted a tour of the outside of the facility, and observed the following. The backyard is free of any hazards or obstructions a long the exit routes. LPA observed a fully fenced pool with the fence measuring 5ft tall and bars 4 inches apart from one another. Side doors are self latching and unlocked. Based on observations made during today's inspection deficiencies will be issued. LPA Vanegas conducted an exit interview with AD Maria Jiminez and a copy of this report was provided to the facility.
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/27/2026 04:51 PM - It Cannot Be Edited


Created By: William Vanegas On 01/27/2026 at 04:30 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: SADDLEBACK FMJ III ELDERLY CARE HOME
FACILITY NUMBER: 306003067

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87466
Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above due to no clients having any weight records readly available for review which poses potential health risk to persons in care.
POC Due Date: 02/03/2026
Plan of Correction
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Administrator agrees to weigh and document the weights of each resident, and send proof to LPA via email by POC due date.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three out of three staff not having a valid CPR/First aid certificate which poses a potential health and safety risk to persons in care.
POC Due Date: 02/03/2026
Plan of Correction
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Administrator agrees to schedule all staff to complete CPR/First aid certification, and to send proof of completion to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:
William Vanegas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2026


LIC809 (FAS) - (06/04)
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