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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006715
Report Date: 09/13/2026
Date Signed: 09/13/2026 11:06:30 AM

Document Has Been Signed on 09/13/2026 11:06 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 HOMEFACILITY NUMBER:
306006715
ADMINISTRATOR/
DIRECTOR:		QUIOGUE,MARIAFACILITY TYPE:
740
ADDRESS:10611 CEDARHILL CIRCLETELEPHONE:
(714) 617-0599
CITY:VILLA PARKSTATE: CAZIP CODE:
92861
CAPACITY: 6CENSUS: 3DATE:
09/13/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:33 AM
MET WITH:Alice DabuTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samer Haddadin conducted an announced case management visit to the facility. LPA Haddadin was greeted and granted entry by Alice Dabu. The purpose of the visit was to address deficiencies identified during the investigation of complaint # 22-AS-20260512142639- The following deficiencies were observed: On May 8, 2026, Resident 1 (R1) sustained an unwitnessed fall in the living room area of the facility. Interviews established that one staff member was near the living room at the time of the incident but did not directly observe the fall. A second staff member, who was in the nearby garage area, heard R1 fall and subsequently observed R1 on the floor. Staff assisted R1 from the floor and placed R1 in a seated position.
Staff reported that they did not initially observe any bleeding or other visible injuries; however, R1 complained of head pain. Staff asked R1 whether they wanted 911 to be contacted, but R1 requested that their family be notified instead. Staff did not call 911. Instead, staff contacted the Facility Administrator (AD), who was not present at the facility. The AD then notified R1’s family member by text message regarding the fall. R1’s family member arrived and reported R1 also demonstrated confusion and difficulty recalling information.R1 was later observed by a nurse practitioner at the facility who stated that, based on R1’s condition and diagnosis, R1 should have been transported to the hospital sooner.R1 passed away on May 15, 2026. R1’s death certificate identified the immediate cause of death as Traumatic Intracerebral Hemorrhage.
Based on record review, the following are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report, confidential names list and appeal rights were provided at the time of exit.
Alisa Ortiz
Samer Haddadin
DATE: 09/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2026
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 09/13/2026 11:06 AM - It Cannot Be Edited


Created By: Samer Haddadin On 09/12/2026 at 03:36 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: ST JUDE CARE HOME
FACILITY NUMBER: 306006715

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/14/2026
Section Cited
CCR
87465(g)

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87465(g) “The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident's health...”
This requirement was not met as evidenced by interviews and
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The Administrator will provide staff training on Section 87465(g), including when staff are required to immediately call 911 following an injury or circumstance
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record review. R1 sustained an unwitnessed fall. Staff failed to immediately call 911, resulting in hospitalization with intracerebral hemorrhage. This poses an immediate health and safety risk to resident in care.
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that presents an imminent threat to a resident’s health. Proof of completed staff training, including the training date, topics covered, and staff signatures, will be submitted to LPA by the POC due date.

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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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Samer Haddadin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2026


LIC809 (FAS) - (06/04)
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