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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300606700
Report Date: 03/11/2024
Date Signed: 03/11/2024 12:29:33 PM

Document Has Been Signed on 03/11/2024 12:29 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
ORANGE COUNTY ASC, 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: 4DATE:
03/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Elizabeth Maldonado - AdministratorTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of
conducting an annual inspection. LPA was greeted and granted entry by Administrator Elizabeth Maldonado.

The facility is a two-story home. The first floor houses the family room, living room, dining room, kitchen, staff bedroom, staff bathroom, backyard and attached 2-car garage. The second floor houses 4 client rooms, one common bathroom and one private bathroom. One of the client rooms is vacant. Facility appears clean, safe and sanitary. All residents rooms had required elements, including bed, chair, closet space and ample lighting. Facility has extra linens and hygiene supplies for clients in the upstairs hallway closet. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured at 105.3 degrees Fahrenheit in the upstairs common bathroom. LPA advised Administrator to maintain a water log seeing as the hot water measured closed to the threshold. A Technical Assistance was issued. LPA observed facility has emergency food and water supply stored in the closet in the entryway. LPA observed the fire extinguisher was charged based on the arrow on the extinguisher's meter pointing into the green zone. The service tag indicates the extinguisher was last serviced on January 9, 2024. AD tested smoke and carbon monoxide detectors. LPA observed the detectors to be operational. LPA noted the facility has one single knife that remains locked up in the staff room. Chemicals and toxins are locked up in the garage. LPA noted the facility's knife is locked up separate from the toxic chemicals. Medication for each resident is kept locked in a cabinet in the garage. Files are stored at a desk in the family room. The backyard has one shaded seating area. The exit gate is unlocked. LPA advised facility to hire someone to cut the bottom couple of inches of the wooden side gate to avoid the bottom of the gate dragging along the dirt and grass beneath it. LPA observed exit gate to be otherwise unobstructed. LPA reviewed all four client files, medications and P&I records. LPA reviewed three staff files and interviewed one staff member and one client.

No deficiencies were noted during today's inspection. An exit interview was conducted and a copy of this report was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2024
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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