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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005972
Report Date: 11/21/2025
Date Signed: 11/21/2025 04:23:10 PM

Document Has Been Signed on 11/21/2025 04:23 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: 5DATE:
11/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:BrianTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On November 21, 2025, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Bentley introduced self and was granted entry into the facility by staff, after stating the purpose of the visit. Licensee (LI) Brian Estorba arrived at the facility and remained to assist during the visit.

The facility is licensed to operate for six (6) non-ambulatory residents of which one (1) may be bedridden, with a hospice waiver for five (5) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) resident bedrooms, three (3) staff bedrooms, six (6) bathrooms, living area, dining area, kitchen, an outdoor covered seating areas, and an attached two car garage.

During the visit, LPA toured inside and outside of the physical plant with LI Estorba There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be clean and operational. Medications and sharps objects were observed unlocked and accessible to residents in care and a deficiency was cited. The water temperature in five resident bathrooms measured between 105.4 degrees F to 116.6 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly.

CONTINUE TO LIC809-C......

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2025
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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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: SAINT JOSEPH HOME'S FV
FACILITY NUMBER: 306005972
VISIT DATE: 11/21/2025
NARRATIVE
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The facility has two (2) fire extinguishers that were charged and serviced on September 19, 2025. Emergency food, emergency water, and emergency supplies were observed. A working telephone (657)259-0700 remains available, however the facility does not currently have a device that can be used for video teleconference purposes. LPA provided Technical Assistance. The smoke detectors and carbon monoxide detectors were operable. First aid kit is maintained and contains all the necessary elements. Emergency safety drills were last conducted on April 10, 2025 and no record of current Liability Insurance was provided during the visit. Deficiencies were cited.

LPA conducted an audit of five (5) resident files (R1-R5), five (5) staff files (S1-S5), and medication and medication administration review. Resident and staff interviews were conducted.

Deficiencies were cited during this visit, as per Title 22 Division 6 Chapter 8 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report, LIC809-D, Technical Violation, Technical Assistance, and appeal rights were provided to Licensee Brian Estorba at exit.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 11/21/2025 04:23 PM - It Cannot Be Edited


Created By: Eboni Bentley On 11/21/2025 at 11:48 AM
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: SAINT JOSEPH HOME'S FV
FACILITY NUMBER: 306005972

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, licensee did not comply with the section cited above as two black roaches were observed on the wall in the kitchen. This poses an immediate risk to persons in care.
POC Due Date: 11/22/2025
Plan of Correction
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Licensee stated they will deep clean kitchen and all rooms, as well as schedule pest control appointment to evaluate the entire facility and send proof of appointment made and rooms cleaned to LPA by POC due date. Licensee will send LPA pest control reports to LPA once obtained.
Type A
Section Cited
CCR
87355(e)(3)
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on a record review Staff 3 (S3) does not have a transfer of their criminal record as required by the Department. This poses an immediate health, safety and personal rights risk to residents in care. Licensee and staff stated S3 has worked at facility for more than 3 years. CIVIL PENALTY ASSESSED.
POC Due Date: 11/22/2025
Plan of Correction
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Licensee agrees to have all staff background cleared/transferred and associated to the facility before allowing any staff to work at the facility. Licensee agrees to sign a statement of understanding of CCR 87355 and to provide the signed statement by the 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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2025


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 11/21/2025 04:23 PM - It Cannot Be Edited


Created By: Eboni Bentley On 11/21/2025 at 11:58 AM
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: SAINT JOSEPH HOME'S FV
FACILITY NUMBER: 306005972

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed the Licensee does not currently have liability insurance for the facility. LPA observed a proposal for liability insurance dated June 17, 2025 and no additional records were provided during the visit.
POC Due Date: 11/22/2025
Plan of Correction
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The Licensee stated that they have current liability insurance and are in the process of obtaining record from insurance agent. The Licensee stated that they will provide LPA proof of liability insurance once it has been obtained. The Licensee agreed to provide LPA the liability insurance via email or fax by POC date.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. LPA observed unsecured scissors and medication in R1's bedroom. R1 has a diagnosis of dementia. Sharps were also observed unlocked in a cabinet in the kitchen, which poses an immediate risk to residents in care.
POC Due Date: 11/22/2025
Plan of Correction
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LPA observed licensee remove items from resident's room and licensee stated the lock on kitchen cabinet will be repaired. Licensee stated they will retrain staff and will send proof of completed training, with attendee signatures, to CCLD via email 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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2025


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 11/21/2025 04:23 PM - It Cannot Be Edited


Created By: Eboni Bentley On 11/21/2025 at 11:58 AM
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: SAINT JOSEPH HOME'S FV
FACILITY NUMBER: 306005972

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not ensure the facility staff received fire, emergency, and disaster training quarterly, as the last training was conducted on April 10, 2025. This poses a potential safety risk to persons in care.
POC Due Date: 11/28/2025
Plan of Correction
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Licensee stated they will have all staff participate in fire, emergency, and disaster training and submit proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2025


LIC809 (FAS) - (06/04)
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