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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005972
Report Date: 06/23/2021
Date Signed: 06/23/2021 04:01:42 PM

Document Has Been Signed on 06/23/2021 04:01 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SAINT JOSEPH HOME'S FVFACILITY NUMBER:
306005972
ADMINISTRATOR:CRUZ, LEAHFACILITY TYPE:
740
ADDRESS:9371 EL VALLE AVETELEPHONE:
(714) 488-8413
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
06/23/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Administator, Leah CruzTIME COMPLETED:
04:11 PM
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Licensing Program Analyst (LPA) Jenifer Tirre conducted a visit for the purpose of conducting a Pre Licensing visit. LPA was greeted and granted entry into the facility by Administrator Leah Cruz and explained the reason for the visit.


LPA Tirre along with Administrator Cruz toured the facility.Structure: Facility is a two story, 8 bedroom (6 residents, 2 caregivers) 8 bathroom (6 residents, 2 caregivers) house with an attached garage and a gray exterior. The second floor will not be housing any residents. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: All resident rooms have basic accommodations of closet, dresser, bed, night stand, and chairs. Bathrooms: All resident bathrooms have a working toilet, wash basin, and bathtub/shower as well as grab bars, soap and towels. Linens & Hygiene Supplies: Facility has linens present in each resident room. Emergency Phone Numbers and Exit Plan: Facility has proper postings at the facility. Food Service: Facility has 2 day perishables as well as 7 day non-perishables in the pantry/ refrigerator. Facility has an emergency food and water supply present at the facility. Smoke Detectors: Smoke detectors/ carbon monoxide detector are centrally wired and were tested operational. Fire extinguisher is mounted and charged, Facility has 3 extinguishers. Appliances: Stove and refrigerator are operational. Toxins: Locked in a cabinet Water Temperature: Tested and recorded at 114.6 degrees F. in facility bathrooms. Reading Material Games, and Equipment: Facility has area for board games, karaoke and exercises. Medications, First-Aid Kit & Book: Facility has first aid kit and manual present at the facility. LPA observed completed emergency disaster plan. Facility has a secured location for medications and facility files. Backyard: LPA observed the facility perimeter which is secured by wall with self locking gates. LPA observe shaded, outdoor seating for residents. Fire Clearance: Approved for 5 non-ambulatory residents and 1 bedridden on 04/29/2021.
CONTINUED ON LIC 809C DATED 06/23/2021
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2021
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SAINT JOSEPH HOME'S FV
FACILITY NUMBER: 306005972
VISIT DATE: 06/23/2021
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LPA reminded Administrator about Miscellaneous clutter/equipment in backyard area to be removed.

Component III Orientation was waived during this pre-licensing visit due to Administrator having another operational facility. The pre-licensing visit has been completed. This location is ready for licensure.
No deficiencies noted during todays visit.

An exit interview was conducted with Administrator Leah Cruz and a copy of this report was left at facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
LIC809 (FAS) - (06/04)
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