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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005972
Report Date: 10/24/2024
Date Signed: 10/24/2024 02:50:49 PM

Document Has Been Signed on 10/24/2024 02:50 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:SAINT JOSEPH HOME'S FVFACILITY NUMBER:
306005972
ADMINISTRATOR/
DIRECTOR:
CRUZ, LEAHFACILITY TYPE:
740
ADDRESS:9371 EL VALLE AVETELEPHONE:
(714) 488-8413
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
10/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:John Jason EugenioTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to the facility to conduct a Required - 1 year inspection. LPA identified herself and was granted entry into the facility by Caregiver (CG) Ted Abapo. Administrator (AD) John Jason Eugenio's certificate expired on 10/15/2024. Upon entry, LPA noted residents having lunch. Facility appears clean, safe and sanitary. AD Eugenio arrived shortly after.

There are 6 Residents of which 4 are receiving Hospice care and 2 staff present during today's visit. LPA, along with AD Eugenio toured the physical plant. LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each Resident comfortably. Bathrooms were checked, toilets/water faucets worked properly and shower was free of mold/mildew. Hot water temperature was within regulatory requirements. Bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions. Kitchen is clean and organized. Perishable and non-perishable food supply was checked and adequately stocked. LPA observed sharps and cleaning supplies are inaccessible to the residents. Smoke detectors and carbon monoxide detector tested operational; Fire extinguisher was fully charged and mounted. No bodies of water were observed outside. Walkways around the home were clear of hazards. Exit gates are unlocked and self-latching. Backyard has a covered patio with patio furniture for outdoor activities and sufficient seating for Residents and visitors. Emergency/Fire Drills are conducted last one being 06/12/2024. LPA observed emergency supplies including food and water. LPA reviewed 6 Resident files and 2 staff file. Resident files contained required documentation such as health assessments and admission agreements. Staff files contained required documentation including fingerprint clearance. Medication was observed to be in a centrally stored location and medication reviewed appeared to have been dispensed accurately.



Based on the observations made during today’s visit, no deficiency is being cited. This report was discussed with the facility Administrator and a copy of LIC9102 Advisory were sent to email on file.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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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