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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005675
Report Date: 11/25/2024
Date Signed: 11/25/2024 04:57:25 PM

Document Has Been Signed on 11/25/2024 04:57 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:SANDY CREEK CARE HOME IIFACILITY NUMBER:
306005675
ADMINISTRATOR/
DIRECTOR:		MEJIA, JONALYNFACILITY TYPE:
740
ADDRESS:21596 AUDUBON WAYTELEPHONE:
(562) 301-8265
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 6DATE:
11/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:25 PM
MET WITH:Wilma Fuentes, administrator
Jonalyn Mejia, administrator		TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by caregiving staff after introducing himself and stating the purpose of the visit. Administrators Wilma Fuentes and Jonalyn Mejia were notified via telephone and arrived later to assist with the inspection.

There are currently six residents in care, four of which are receiving hospice care. LPA observed residents participating in activities in the facility’s common areas and relaxing in their respective bedrooms. LPA accompanied by facility caregiver toured the physical plant. The facility is a one-story house with an attached garage. The facility has five (5) resident bedrooms, one (1) of which is shared, one (1) staff bedroom, and two (2) shared bathrooms. All bedrooms appeared clean and sanitary. LPA observed all the resident bedrooms has the required furnishings. Four residents on hospice have beds equipped with full rails and a fifth resident has half-rails in place. All corresponding physician orders and hospice plans of care present on file and reviewed. Both bathrooms appear clean and sanitary. Bathrooms were equipped with grab bars and non-slip mats. Hot water temperature measured between 115 and 117.8 degrees Fahrenheit.

LPA observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. LPA observed knives locked in a secure drawer inside the kitchen. A fire extinguisher is located across from the kitchen and was observed to have been purchased in 2024 based on the receipt attached. LPA tested the smoke and carbon monoxide detectors which were found to be operational. The centrally stored medication is located in a locked cabinet in the dining room. Hospice comfort kit are placed in lockboxes in the garage refrigerator. The attached garage is inaccessible to residents and is used for storage and for laundry. Cleaning supplies are located in the garage as well as under the kitchen sink in a locked cabinet. LPA observed the facility has an emergency food and water supply which is also stored in the garage.
CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
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 3
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: SANDY CREEK CARE HOME II
FACILITY NUMBER: 306005675
VISIT DATE: 11/25/2024
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CONTINUED FROM FORM LIC809
LPAs and administrator toured the outside of the facility and observed it to be free of obstructions. LPAs observed a shaded outdoor seating area with furniture for resident use. The perimeter gates on both sides of the property are self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.

LPAs reviewed six resident records and reviewed all necessary components. All necessary documents observed and present. Medical assessments have been updated in a timely manner. LPA reviewed resident medication records. No discrepancies were observed. LPA interviewed one resident. LPA reviewed ten staff records which were found to be complete. Training and CPR/First aid training reviewed and up-to-date. All staff are background cleared and associated to the licensed location accurately. Infection Control and Emergency and Disaster plans were both reviewed and are complete and accurate. Both have been reviewed annually by the administrator. Fire and emergency drills are conducted quarterly and documented as required.

Based on the observations made during today’s visit, there are no deficiencies being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC809 (FAS) - (06/04)
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