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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006303
Report Date: 09/26/2025
Date Signed: 09/26/2025 12:16:19 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/19/2025 and conducted by Evaluator Alvaro Ramirez Jr.
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250919120324
FACILITY NAME:CARE SAINT JACOBFACILITY NUMBER:
306006303
ADMINISTRATOR:JULIE G CORNEJOFACILITY TYPE:
740
ADDRESS:4110 E JORDAN AVETELEPHONE:
(714) 289-1946
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:6CENSUS: 6DATE:
09/26/2025
UNANNOUNCEDTIME BEGAN:
08:31 AM
MET WITH:Joselene Poy Lorenzo-Caregiver, Julie Cornejo-AdministratorTIME COMPLETED:
12:31 PM
ALLEGATION(S):
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Staff hit a resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced initial 10-Day complaint visit to initiate the investigation into the above allegation and to deliver the findings of the investigation. LPA was greeted and granted entry into the facility and met with Caregiver Joselene Poy Lorenzo. LPA explained the reason for the visit. Administrator (AD) Julie Cornejo arrived shortly after.

This agency has investigated the complaint alleging that staff hit a resident in care. Regarding the allegation, the following was revealed: During the course of the interviews one of eight individuals interviewed confirmed the allegation. During the course of the interviews Resident 1 (R1) reported that he was walking in the common area when Staff 1 (S1) pushed him against the wall and started punching him until he broke his ribs. Per R1, the incident happened at night. During the course of the investigation LPA reviewed document including the UCI Health after visit summary dated September 14, 2025, for R1. Per UCI Health after visit summary findings R1 does not have acute displaced left rib fractures and no acute osseous abnormality.
CONTINUED ON LIC9099-C..
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 22-AS-20250919120324
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: CARE SAINT JACOB
FACILITY NUMBER: 306006303
VISIT DATE: 09/26/2025
NARRATIVE
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LPA also reviewed documents including the Personnel Report (LIC500) dated May 1, 2025, for Care Saint Jacob. Per Personnel Report, S1 was schedule to work Wednesday through Sunday from 7:00 a.m. to 7:00 p.m. During the course of the interviews with residents, R2 reported that S1 is attentive and a good worker. Per R2, S1 never hit her and/or handled her in a rough manner. R3 reported that he has never been hit by staff. R3 stated that S1 is a very good staff and reported that staff are good and respectful. During the course of the interviews with staff, S2 reported that S1 never hit the residents. Per S2, S1 is nice and treats the residents good.

Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED.

For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations.


LPA conducted an exit interview with facility AD Cornejo, and a copy of this report was provided to the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
LIC9099 (FAS) - (06/04)
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