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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006303
Report Date: 12/27/2023
Date Signed: 12/27/2023 02:16:34 PM

Document Has Been Signed on 12/27/2023 02:16 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 JACOBFACILITY NUMBER:
306006303
ADMINISTRATOR:AMORSOLO, LEONORA CHERYLLFACILITY TYPE:
740
ADDRESS:4110 E JORDAN AVETELEPHONE:
(714) 289-1946
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY: 6CENSUS: 6DATE:
12/27/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Leonora Cheryll AmorsoloTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection to follow-up on corrections identified during visit on 12/15/2023. LPA arrived at the facility and was greeted and granted entry by 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.

At 1:00 p.m. LPA toured the facility and observed the following:

· The flooring in bedroom 1 has been replaced and no longer poses a tripping hazard.

· All four gas burners on stove tested operable.

· Non-skid mats have been placed in every resident bathroom.

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

· Facility has recreational and reading material for resident use, including crosswords and activity books.

All items noted for correction during inspection on 12/15/2023 have been addressed.

Component III was conducted during this inspection, information provided about how to operate the facility within compliance and reporting requirements. The facility is ready to be licensed. The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau (CAB) in Sacramento. An exit interview was conducted, and a copy of this report was left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2023
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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