Care Saint Jacob

Type of visit: Required - 1 Year

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... 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.the state’s words, verbatim · CDSS document, Jan 9, 2026

Allegation investigated: Staff do not ensure there is enough food to meet the needs of residents The facility is understaffed to meet the resident needs

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced initial 10-Day complaint visit to initiate the investigation into the above allegations 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 do not ensure there is enough food to meet the needs of residents. Regarding the allegation, the following was revealed: During the course of the interviews five of six individuals interviewed denied the allegation. During the investigation LPA reviewed the Care Saint Jacob food menu. Per food menu, the residents are offered a different meal for breakfast, lunch and dinner throughout the week. Per food menu, the residents are provided snacks in between meals. During the course of the interviews with residents, Resident 1 (R1) reported that he gets a meal for breakfast, lunch and dinner. Per R2, staff give the residents enough food and stated that she gets three meals per day. CONTINUED ON LIC9099-C... Unsubstantiated R3 reported that he gets plenty of food and stated that staff go out of their way with the meals. During the course of the interviews with staff, Staff 1 (S1) reported that they have enough food to meet the resident needs and stated that no resident has complained about not getting enough food. Per S2, the residents get three meals per day plus snacks. S2 stated that the residents can get seconds or can substitute an item they do not like. Regarding the allegation that the facility is understaffed to meet the resident needs, the following was revealed: During the investigation LPA reviewed the Personnel Report (LIC500) dated December 1, 2025. Per Personnel Report there are two caregiver for the day shift from 7:00 a.m. to 7:00 p.m. and one caregiver for the night shift from 7:00 p.m. to 7:00 a.m. During the initial visit LPA observed two caregivers on duty for six residents in care. During the course of the interviews with residents, R1-R3 reported that they have enough staff to care for the residents and/or stated that staff helps within a reasonable time. During the course of the interviews with staff, S1 reported that they have enough staff to care for the residents. Per S2, they have enough staff to care for the residents and get their job done. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, these allegations are 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 representative Poy Lorenzo, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Dec 17, 2025 · control 22-AS-20251212145050

Allegation investigated: Staff hit a resident in care.

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 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.the state’s words, verbatim · CDSS document, Sep 26, 2025 · control 22-AS-20250919120324

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit for the purpose of conducting the required annual inspection. LPA was greeted and granted entry by caregiver staff after explaining the purpose for the visit. Administrator (AD) Julie Cornejo was notified via telephone and later arrived to assist with the inspection. LPA observed that Administrator Julie Cornejo has a valid Administrator 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 room, three resident bathrooms, two of which are shared, a living room, a dining room, a kitchen, a laundry room, and an attached two car garage. LPA accompanied by the AD conducted a tour of the physical plant. On today's visit, LPA observed six residents in care and three caregiver staff present. LPA observed residents relaxing in their respective bedrooms. LPA observed the See Something, Say Something poster (PUB 475) mounted on a wall by the entryway of the facility. LPA inspected all six resident bedrooms, and they were observed to be free of any hazards. LPA observed the resident bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. All resident beds had clean linens and blankets. LPA observed additional linens are stored in a hallway closet. LPA inspected the three resident bathrooms. Resident bathrooms are clean. Bathrooms are equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 108.6 and 114.6 degrees Fahrenheit. LPA observed the staff room is kept locked and inaccessible to residents in care. LPA observed the kitchen has a two day perishable and seven day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. The five burner gas stove lights unassisted. LPA observed kitchen knives are stored in a locked kitchen cabinet. LPA observed chemicals and toxins to be stored in a locked kitchen cabinet under the sink. CONTINUED ON LIC809-C A fire extinguisher is located in the kitchen and in the laundry room. Fire extinguishers were observed the be charged and serviced as of September 26, 2024. LPA tested the wired smoke detectors/carbon monoxide detectors which tested operational. LPA observed the facility conducted their last emergency disaster drill on October 23, 2024. The centrally stored medication is kept in a locked closet in the resident hallway. LPA observed Personal Protective Equipment and a First Aid Kit to be stored in the closet in the resident hallway. LPA observed the First Aid Kit has all the required components. Chemicals and toxins were observed to be stored in a locked cabinet in the laundry room. The door leading to the attached two car garage is kept locked and inaccessible to resident. The garage is used for storage and laundry. LPA observed chemicals to be stored in the locked two car garage. LPA observed the facility has a three day emergency food and water supply stored in the garage. LPA and AD conducted a tour of the exterior portion of the facility. LPA observed the exterior portion to be clear of obstructions and hazards. LPA observed a shaded outdoor seating area with furniture for resident use. The perimeter gate on the west side of the facility is self-latching and can be opened in an evacuation. There are no bodies of water on the premises. LPA reviewed all six resident files. LPA observed that the Reappraisals for Resident #1, Resident #2, Resident #3, and Resident #6 were outdated. LPA observed that Resident #5 did not have a Reappraisal on file. LPA observed that Resident #2 did not have an Admission Agreement on file. LPA reviewed six residents’ medication and medication records. LPA reviewed four staff files. All staff are background cleared and associated to the facility. Based on today's observations, deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Julie Cornejo. A copy of the report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Jan 27, 2025

Allegation investigated: Staff are mismanaging resident medication

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the initial investigation into the allegation listed above. LPA was greeted and granted entry by caregiving after introducing himself and stating the reason of the visit. Administrator Julie Cornejo was notified of the visit by telephone and agreed to review the final report with LPA prior to authorizing her caregiving staff to sign on her behalf. LPA accompanied by caregiver conducted a tour of the physical plant. LPA conducted private interviews with the six residents currently in care at the facility and reviewed the medication orders and medication administration records for all six residents. LPA assisted by facility staff also verified the content of the medication central storage for residents R1 and R2 which were both observed to be consistent with the refilling cycle and accurate dispensation to the residents in question. CONTINUED ON FORM LIC9099-C Unfounded CONTINUED FROM FORM LIC9099 Based on the observation of the facility's medication administration records, physician orders on file as well as interviews conducted with all six residents currently admitted at the facility, LPA was unable to find any evidence that Staff are mismanaging resident medication. The allegation is therefore determined to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. The Department has investigated this complaint. A copy of this report is being reviewed with facility representative via telephone and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Apr 24, 2024 · control 22-AS-20240417083208

Type of visit: Prelicensing

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.the state’s words, verbatim · CDSS document, Dec 27, 2023

Type of visit: Prelicensing

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. 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. 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.the state’s words, verbatim · CDSS document, Dec 15, 2023

The state marks this report as 6 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Office

Component II completion: Successful Facility Type: RCFE Application Type: chow Capacity: 6 Census (if any clients in care): 6 COMP II Participants: Librada, Leonora Cheryll Amorsolo (administrator), Marian Mejia (applicant/licensee) Interview Method: micrsosoft teams On 11/17/23, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Nov 17, 2023