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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005808
Report Date: 01/29/2026
Date Signed: 01/29/2026 01:58:46 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/23/2024 and conducted by Evaluator Brandon Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240423163628
FACILITY NAME:ST. JOSEPH'S HOMEFACILITY NUMBER:
306005808
ADMINISTRATOR:FAJARDO, MIGUELITOFACILITY TYPE:
740
ADDRESS:24671 ELOISA DRIVETELEPHONE:
(949) 305-1175
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
01/29/2026
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Leah Fajardo via telephoneTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility staff do not properly assist resident with toileting needs overnight
Licensee did not ensure suppositories are administered by resident or an appropriately skilled professional
INVESTIGATION FINDINGS:
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On January 29, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Administrator (AD) Leah Fajardo was notified via telephone but was unable to assist with today’s inspection.

During the course of the investigation, the Department interviewed residents, interviewed staff, reviewed and obtained pertinent documents for this complaint. Regarding the allegation, facility staff do not properly assist resident with toileting needs overnight, the following has been concluded: It was alleged that facility staff did not properly assist Resident #1 (R1) with toileting needs overnight. The Department was unable to conduct an interview with R1 for this allegation due to R1 passing away on November 12, 2024. The Department reviewed R1’s Reappraisal dated March 28, 2024, which stated that R1 required assistance with toileting and with incontinence care. The Department conducted five resident interviews. Three out of the five residents were unable to be qualified for an interview. CONTINUED ON LIC9099-C
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 22-AS-20240423163628
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ST. JOSEPH'S HOME
FACILITY NUMBER: 306005808
VISIT DATE: 01/29/2026
NARRATIVE
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Two out of the five residents interviewed stated that they do not require assistance with incontinence care. The Department conducted four staff interviews. Four out of the four staff interviewed confirmed that R1 was receiving assistance from the facility with incontinence care. Staff interviewed stated that the facility would put two diapers, and a liner on R1 at night for her incontinence issues, since the facility does not provide awake staff overnight. However, three out of the four staff interviewed stated that there were incidents in which R1 was soiled in the morning since she was not being changed overnight.

Regarding the allegation, licensee did not ensure suppositories are administered by resident or an appropriately skilled professional, the following has been concluded: It was alleged that the licensee did not ensure suppositories were administered to R1 by an appropriately skilled professional. The Department was unable to conduct an interview with R1 for this allegation due to R1 passing away on November 12, 2024. The Department reviewed R1’s Physician Report dated March 28, 2024, which stated that R1 was unable to administer her own prescription medications. The Department conducted four staff interviews. Four out of the four staff interviewed denied the allegation and stated that suppositories were administered by R1’s hospice agency. The Department reviewed R1’s medication administration records. The Department observed that R1 was administered a suppository on April 7, and July 16, 2024. The Department reviewed R1’s hospice visitation log and observed that R1 was visited on July 16, 2024, but was not visited on April 7, 2024. Therefore, a suppository was administered to R1 on April 7, 2024, without an appropriately skilled professional present.

Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the allegations that, facility staff do not properly assist resident with toileting needs overnight and licensee did not ensure suppositories are administered by resident or an appropriately skilled professional. The preponderance of evidence standards has been met; therefore, the above allegations are SUBSTANTIATED. Deficiencies are being cited on the attached LIC9099-D pages. An exit interview was conducted via telephone with Administrator Leah Fajardo. A copy of the report and Appeal Rights were provided to an authorized facility representative.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 22-AS-20240423163628
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ST. JOSEPH'S HOME
FACILITY NUMBER: 306005808
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/27/2026
Section Cited
CCR
87625(b)(2)
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87625 Managed Incontinence: (b) ... the licensee shall be responsible for the following: (2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night.
This requirement was not evidenced by:
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The Administrator stated that she will complete a written statement to comply with the regulation with any future residents that may require assistance with incontinence needs. The Administrator agreed to provide LPA the written statement via email or fax by POC date.
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Based on records reviewed and interviews conducted, the Licensee did not ensure that R1 was properly assisted with toileting needs overnight. This poses a potential health, safety, and personal rights risk to persons in care.
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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.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 22-AS-20240423163628
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ST. JOSEPH'S HOME
FACILITY NUMBER: 306005808
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/30/2026
Section Cited
CCR
87622(a)(2)
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87622 Fecal Impaction Removal, Enemas, and/or Suppositories: (a) The licensee shall be permitted to accept.. a resident who requires .. suppositories .. (2) ..suppositories shall be.. administered.. by either the resident or an appropriately skilled professional.
This requirement was not evidenced by:
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The Administrator stated that she will conduct an in-service training with all facility staff regarding the administration of suppositories. The Administrator stated that she will provide proof of the training to LPA via email or fax by POC date.
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Based on records reviewed and interviews conducted, the Licensee did not ensure that a suppository was administered to Resident #1 (R1) by an appropriately skilled professional on 4/7/24. This poses an immediate health, safety, and personal rights risk to persons in care.
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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.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/23/2024 and conducted by Evaluator Brandon Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240423163628

FACILITY NAME:ST. JOSEPH'S HOMEFACILITY NUMBER:
306005808
ADMINISTRATOR:FAJARDO, MIGUELITOFACILITY TYPE:
740
ADDRESS:24671 ELOISA DRIVETELEPHONE:
(949) 305-1175
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
01/29/2026
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Leah Fajardo via telephoneTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
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5
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7
8
9
Facility staff did not ensure the resident's call buttons were within reach of the resident
INVESTIGATION FINDINGS:
1
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3
4
5
6
7
8
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10
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13
On January 29, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Administrator (AD) Leah Fajardo was notified via telephone but was unable to assist with today’s inspection.

During the course of the investigation, the Department interviewed residents, interviewed staff, reviewed and obtained pertinent documents for this complaint. Regarding the allegation, facility staff did not ensure the resident's call buttons were within reach of the resident, the following has been concluded: It was alleged that facility staff did not ensure Resident #1 (R1) call button was within reach. The Department was unable to conduct an interview with R1 for this complaint due to R1 passing away on November 12, 2024. The Department conducted five resident interviews. Three out of the five residents were unable to be qualified for an interview. Two out of the five residents interviewed stated that they do not have a call button since they do not require that level of care from the facility. CONTINUED ON LIC9099-C
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 22-AS-20240423163628
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ST. JOSEPH'S HOME
FACILITY NUMBER: 306005808
VISIT DATE: 01/29/2026
NARRATIVE
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The Department conducted four staff interviews. Four out of the four staff interviewed denied the allegation and stated that call buttons have always been available and within reach of residents.

Due to conflicting information received during the investigation, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED. An exit interview was conducted via telephone with Administrator Leah Fajardo. A copy of the report was provided to an authorized facility representative.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6