<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202569
Report Date: 09/21/2020
Date Signed: 10/01/2020 09:46:57 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MADONNA GARDENSFACILITY NUMBER:
275202569
ADMINISTRATOR:HELEN HURLEYFACILITY TYPE:
740
ADDRESS:1335 BYRON DRTELEPHONE:
(831) 758-0931
CITY:SALINASSTATE: CAZIP CODE:
93901
CAPACITY:88CENSUS: 43DATE:
09/21/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Executive Director Patty KingTIME COMPLETED:
05:30 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
Licensing Program Analysts(LPAs) Steve Chang and Grace Davis, conducted an unannounced Case Management via telephone. Due to COVID-19 preventive measures, facility visits have been suspended. LPAs interviewed with Patty King Executive Director (ED).

On 9/21/2020, LPAs called the facility and spoke with Executive Director(ED) Patty King. The purpose of this visit was to obtain additional information on an incident report reported to CCLD by the facility on 09/14/2020 regarding an alleged abuse towards a resident (R1) by a staff (S1).

Per ED, S1 was interviewed and denied the allegation. S1 is currently taken off from work pending facility investigation. R1 was interviewed and R1 did not have recollection of the alleged abuse or incident. R1 did not sustain any injuries.

ED will communicate with CCLD about the facility investigation findings at later date.

LPAs requested to submit the following documents like LIC500, Staff Schedule, R1's Physician's Report and Appraisal Needs and Services Plan tomorrow, 9/22/2020.

LPAswill conduct interviews with R1, S1 and witnesses at a later date.

No deficiencies cited during today's Tele Inspection Visit. Exit Interview conducted with ED.
A copy of this report is e-mailed to the facility for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1