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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300606700
Report Date: 03/10/2022
Date Signed: 03/10/2022 02:06:21 PM

Document Has Been Signed on 03/10/2022 02:06 PM - 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MALDONADO, ELIZABETH HOMEFACILITY NUMBER:
300606700
ADMINISTRATOR:MALDONADO, ELIZABETHFACILITY TYPE:
735
ADDRESS:10282 ARUNDELTELEPHONE:
(714) 531-5226
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY: 6CENSUS: 2DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Lemuel ElleTIME COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit. Facility staff contacted Administrator (AD) Elizabeth Maldonado via telephone and the AD responded at the end of the visit and spoke to LPA Haley. LPA did not observed the required "See Something Say Something" poster (PUB475) on the walls at entrance of the facility. LPA observed a screening station, with a screening log book, and temperature thermometer for screening clients and visitors. There were two clients present during the visit. At 11:45 am LPA began the tour of the facility. While walking up the stairs to the client bedrooms LPA observed bleach spots on the carpet and a crack in the left bottom corner of the upstairs hallway window. During the inspection of client rooms, LPA observed the clients have the necessary requirements: night stand, chair, lamp and storage space. At 11:50 am while in client room #1 LPA observed there are no curtains on the two bedroom windows. At 12:01 pm while in client room #3 LPA observed the blinds were broken. Bathrooms had soap, sanitizer, and paper towels. In client bathroom #1 LPA measured the water temperature at 105 degrees Fahrenheit. In client bathroom # 2 the water temperature was observed at 100.3 degrees Fahrenheit. At 12:02 LPA observed mold around the bathtub in bathroom #2. LPA toured the garage area of the facility. While in the garage LPA Haley observed a locked cabinet with client medication and a first aid kit with all the necessary requirements. At 12:05 whil in the garage LPA observed a hole in the ceiling. In the kitchen LPA observed a two day supply of perishable food items and seven days supply of nonperishable food items. The stove was clean and three of four burners were operational. LPA observed a dishwasher at 12:15 that was not operational. LPA observed knives and sharp objects in an locked tool box near the sink. LPA observed a missing drawer, and missing knobs to multiple cabinets in the kitchen. The facility has adequate PPE supply of gloves, surgical mask, and hand sanitizers. LPA observed extra linen, emergency food and water supply. In the backyard LPA observed tables and chairs for the clients in care. All smoke detectors were tested and are operational. Fire extinguisher's are mounted and charged. Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview conducted and a copy of the report was provided to the facility staff.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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 3
Document Has Been Signed on 03/10/2022 02:06 PM - It Cannot Be Edited


Created By: Jerome Haley On 03/10/2022 at 01:22 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: MALDONADO, ELIZABETH HOME
FACILITY NUMBER: 300606700

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
The facility shall be kept clean, sanitary and in good repair at all times.
Deficient Practice Statement
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Based on observation of the hole in the garage ceiling, the crack in the upstairs hallway window, and broken and missing blinds in clients rooms, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2022
Plan of Correction
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Administrator states she will start working on making the necessary repairs to the facility immediately.
She states the garage ceiling will be repaired. The dishwasher will be replaced or removed, and the cracked window will be repaired.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Luz Adams
LICENSING EVALUATOR NAME:Jerome Haley
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/10/2022 02:06 PM - It Cannot Be Edited


Created By: Jerome Haley On 03/10/2022 at 01:36 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: MALDONADO, ELIZABETH HOME
FACILITY NUMBER: 300606700

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
All window screens shall be in good repair and be free of insects, dirt and other debris.
Deficient Practice Statement
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Based on [(observation of the dirt present on the screen in the upstairs hallway, and the rips in the screen in client bedroom #3 the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2022
Plan of Correction
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The screen in the upstairs hallway will be replaced or cleaned, and the screen in client bedroom #3 will be replaced.
Type B
Section Cited
CCR
80088(e)(1)

Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of hot water of not lessthan 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
Deficient Practice Statement
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Based on observation of the water temperature in bathroom #2 the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2022
Plan of Correction
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The water temperature in bathroom #2 will be adjusted to meet the regulation requirements.
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:Luz Adams
LICENSING EVALUATOR NAME:Jerome Haley
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022


LIC809 (FAS) - (06/04)
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