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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202569
Report Date: 05/09/2022
Date Signed: 05/09/2022 11:56:12 AM


Document Has Been Signed on 05/09/2022 11:56 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:MADONNA GARDENSFACILITY NUMBER:
275202569
ADMINISTRATOR:PATRICIA KINGFACILITY TYPE:
740
ADDRESS:1335 BYRON DRTELEPHONE:
(831) 758-0931
CITY:SALINASSTATE: CAZIP CODE:
93901
CAPACITY:88CENSUS: 41DATE:
05/09/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator Renee Hamilton TIME COMPLETED:
12:15 PM
NARRATIVE
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On 05/09/22, Licensing Program Analyst (LPA) M. Yang conducted case management visit to the facility. LPA met with Administrator Renee Hamilton stated the purpose of the visit. The purpose of the visit is to address an incident that was reported to the department where R1 went AWOL during an activity at 10:40 a.m. on 04/26/22. R1 was found at 10:45 a.m. by facility neighbors.

A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached 809D.

An exit interview was conducted. Administrator was provided a copy of this report and appeal rights.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022
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 2


Document Has Been Signed on 05/09/2022 11:56 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: MADONNA GARDENS
FACILITY NUMBER: 275202569

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/09/2022
Section Cited

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(a)In each facility: (2) Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice.

This requirement is not met as evidenced by:
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Based on interview and record review, staff did not provide care and supervision when R1 left the facility unsupervised on 04/26/22 at 10:40 a.m. and was located at 10:45 a.m. by facility neighbor which poses an immediate health and safety risks to persons in care.
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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.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2