306006715-6-19-2025-22-AS-SHAN-DHSPVS-20250619113935

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006715
Report Date: 06/19/2025
Date Signed: 06/19/2025 11:40:38 AM

Document Has Been Signed on 06/19/2025 11:40 AM - 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:	ST JUDE CARE HOME		FACILITY NUMBER:	306006715
ADMINISTRATOR/ DIRECTOR:	DAVID, FERNAN		FACILITY TYPE:	740
ADDRESS:	10611 CEDARHILL COURT		TELEPHONE:	(714) 617-0599
CITY:	VILLA PARK	STATE: CA	ZIP CODE:	92861
CAPACITY: 6		CENSUS: 0	DATE:	06/19/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:15 AM
MET WITH:	Maria Quiogue		TIME VISIT/ INSPECTION COMPLETED:	12:30 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	Facility Overview LPA Haddadin was greeted and granted entry by Administrator Maria Quiogue. The facility is a single-story residence featuring five bedrooms and two restrooms. It is approved to accommodate a maximum of six non-ambulatory residents. Physical Plant Inspection During the visit, LPA Haddadin conducted a comprehensive tour and inspection of the facility's physical plant. This inspection included, but was not limited to, testing all smoke detectors, which were found to be operational. Hot water temperatures were verified in both restrooms, ranging from 110.8∘F to 111.9∘F. Audio devices at all exits were also tested. Both fire extinguishers were found to be fully charged and had a purchase date of June 19, 2025. Exterior Inspection The exterior of the facility was inspected, and no bodies of water were observed. The outdoor space is sufficient for resident activities. All emergency exits were checked and confirmed to be clear and free of obstructions. Food Supply and Storage An inspection of the facility's food supply revealed that a seven-day supply of non-perishable food was not on hand. This was attributed to the absence of active residents in the facility at the time of the visit. The administrator stated that a two-day supply of perishable items would be maintained once residents are in care. Knives and cleaning supplies were observed to be securely stored in a kitchen drawer. Administrative and Compliance Review

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025

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: ST JUDE CARE HOME	FACILITY NUMBER: 306006715
	VISIT DATE: 06/19/2025

NARRATIVE

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The PUB 475 notice was posted in the required 20" x 26" size, and visiting hours were clearly posted. Confirmation was obtained that the administrator possesses a current certificate, which expires on November 8, 2025. Component III of the licensing process was successfully completed with the Administrator.
Medication and Safety Equipment
The First Aid Kit was inspected and found to contain all required components. Medication will be stored in a locked cabinet in the garage, ensuring it is inaccessible to residents. All required department postings were observed and displayed near the entrance. The administrator's certificate is also posted and expires on November 13, 2027.
Conclusion
The Administrator was informed that the final application approval would be issued by the Centralized Applications Bureau in Sacramento. An exit interview was conducted, and a copy of this report was provided to the Licensee

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025

LIC809 (FAS) - (06/04)

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