306006303-12-15-2023-22-AS-CGUZ-CYJTZV-20231215141059

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006303
Report Date: 12/15/2023
Date Signed: 12/15/2023 02:11:13 PM

Document Has Been Signed on 12/15/2023 02:11 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:	CARE SAINT JACOB		FACILITY NUMBER:	306006303
ADMINISTRATOR:	AMORSOLO, LEONORA CHERYLL		FACILITY TYPE:	740
ADDRESS:	4110 E JORDAN AVE		TELEPHONE:	(714) 289-1946
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY: 6		CENSUS: 6	DATE:	12/15/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Cheryll Amorsolo		TIME COMPLETED:	02:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA met with designated Administrator (AD) Cheryll Amorsolo. An application to operate a Residential Care Facility for Elderly (RCFE) for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden residents was received by CCL on 1/23/2023. Structure: The facility is a one-story house with six resident bedrooms, one staff bedroom, two and a half bathrooms, living room, kitchen, dining area, laundry room, and attached two car garage. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the entranceway. There is a backyard with an exit gate each side of the house. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard. Resident Bedrooms All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets. LPA observed all windows were screened. Signal system There is no signal system. Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked underneath the kitchen sink and in the garage.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

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: CARE SAINT JACOB	FACILITY NUMBER: 306006303
	VISIT DATE: 12/15/2023

NARRATIVE

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Medications, First-Aid Kit & Book:
Medication will be stored in a locked hallway cabinet. First aid kit is stored below medication cabinet. The first aid kit has all the required elements.

Resident & Staff Files:
Records are kept locked with medication.

Pool/Jacuzzi:
No bodies of water were observed.

Fire Extinguisher:
Fire extinguisher is fully charged.

Reading Material, Games, Equipment & Materials:
The facility does not have any recreational or reading material for resident use.

Fire clearance:
Was approved by a fire inspector of Orange County Fire Authority on 08/01/2023. Special conditions noted, “Fire clearance approved under the above-noted conditions. 1 bedridden client is approved for room #6. All other rooms are for non-ambulatory.”

Bedrooms Staff:
There is one staff bedroom.

Bathrooms:
All bathrooms have working plumbing and designated hand washing posters. Hot water measured between 110.3 and 116.7 degrees Fahrenheit.

Linens & Hygiene Supplies:
A supply of extra linen was stored in the hallway storage.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

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: CARE SAINT JACOB	FACILITY NUMBER: 306006303
	VISIT DATE: 12/15/2023

NARRATIVE

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Emergency Phone Numbers, Exit Plan & Menu:
Posted and available, means of exiting, emergency phone numbers and food menu.

Food Service:
A supply of 2-day perishable and 7-day of non-perishable food was observed and will be maintained on hand.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
One out of four gas burners on stove tested inoperable. Refrigerator, dish washer, microwave, washer, and dryer are operational.

Licensee to address the following corrections:

· The flooring in bedroom 1 has a single crack, is lifted, and shifts as you walk. Flooring must be in place as to not pose a tripping hazard.

· One out of four gas burners on stove tested inoperable. Facility must be in good repair.

· Non-skid mats must be place in every resident bathroom.

· All bins used to discard solid waste must have a tight-fitting lid.

· Facility must obtain and maintain recreational and reading material for resident use.

LPA will make an additional announced visit to follow-up on corrections listed above. An exit interview was conducted and a copy of this report was provided to designated AD.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC809 (FAS) - (06/04)

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