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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006303
Report Date: 01/09/2026
Date Signed: 01/09/2026 04:15:57 PM

Document Has Been Signed on 01/09/2026 04:15 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:CARE SAINT JACOBFACILITY NUMBER:
306006303
ADMINISTRATOR/
DIRECTOR:		JULIE G CORNEJOFACILITY TYPE:
740
ADDRESS:4110 E JORDAN AVETELEPHONE:
(714) 289-1946
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY: 6CENSUS: 5DATE:
01/09/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:02 PM
MET WITH:Joselene Poy Lorenzo-Caregiver, Julie Cornejo-AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. made an unannounced visit for the purpose of conducting the required annual inspection. LPA was greeted and granted entry by caregiver Joselene Poy Lorenzo. Administrator (AD) Julie Cornejo arrived shortly after. LPA observed that AD Julie Cornejo has a valid AD certificate which expires on June 3, 2026.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents, of which one may be bedridden, with a hospice waiver for six. The facility is a single story home with six private resident bedrooms, one staff bedroom, three bathrooms, two of which are shared, a living room, a dining room, a kitchen, a laundry room, and an attached two car garage. LPA and staff tour the interior and exterior of the facility. On today's visit, LPA observed five residents in care and two staff present. LPA observed residents relaxing in their respective bedrooms and/or exercising. LPA observed the See Something, Say Something poster (PUB 475) mounted on a wall by the entryway of the facility. LPA toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detectors and auditory exit alarms were tested and operational. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested between 105.6 and 109.9 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguishers were charged and one was located by the laundry room and one by the living room. Fire extinguishers were service on September 23, 2025.

CONTINUED ON LIC809-C...

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Alvaro Ramirez Jr.
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2026
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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Document Has Been Signed on 01/09/2026 04:15 PM - It Cannot Be Edited


Created By: Alvaro Ramirez Jr. On 01/09/2026 at 03:38 PM
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: CARE SAINT JACOB
FACILITY NUMBER: 306006303

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2026

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 record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/16/2026
Plan of Correction
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Licensee to conduct quarterly drills taking into account different emergency scenarios and email POC 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.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Alvaro Ramirez Jr.
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2026


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CARE SAINT JACOB
FACILITY NUMBER: 306006303
VISIT DATE: 01/09/2026
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LPA observed the emergency disaster and evacuation plan which is located by the entrance. Facility had back-up emergency food and water supply.

LPA observed that the First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to residents in care. Medications are locked in a cabinet by the residents' bedroom hallway.

For the exterior portion, LPA observed a shaded area, patio furniture, and the grounds were free of any hazards. There are two gates in the backyard, which both are self-closing and self-latching. No bodies of water were observed.

LPA reviewed five resident files and three staff files. LPA interviewed residents and staff present. LPA reviewed the facility records and did not observe a log for quarterly drills; a citation is being issued today.

For today's visit one deficiency was issued per Title 22 Division 6 of the California Code of Regulations

LPA advised AD to use the general email address:


CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

An exit interview was conducted with AD Cornejo.

A copy of this report and Appeal Rights were provided at the time of exit.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Alvaro Ramirez Jr.
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2026
LIC809 (FAS) - (06/04)
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