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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001577
Report Date: 12/13/2023
Date Signed: 12/13/2023 11:14:31 AM


Document Has Been Signed on 12/13/2023 11:14 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:RIDGE GATE HAVENFACILITY NUMBER:
306001577
ADMINISTRATOR:JULITO MADRIGALFACILITY TYPE:
740
ADDRESS:4447 RIDGE GATE ROADTELEPHONE:
(714) 998-7803
CITY:ANAHEIM HILLSSTATE: CAZIP CODE:
92807
CAPACITY:6CENSUS: 0DATE:
12/13/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Zenaida Madrigal - OwnerTIME COMPLETED:
11:30 AM
NARRATIVE
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LPA Dwayne Mason Jr. arrived at the facility for the purpose of following up on deficiencies issued during the 10/18/2023 annual inspection.

LPA was greeted and granted entry by owner Zenaida Madrigal. Owner stated to LPA that Administrator (AD) Julito Madrigal was out of the country again and not able to be reached. LPA confirmed via interview, facility tour and record review that the facility has not:

1. Paid licensing fees
2. Scheduled any service for fire extinguishers
3. Changed workout room back into a resident room
4. Scheduled CPR training for staff

The facility is receiving the same four citations issued at the annual inspection in October 2023. Owner agreed to a POC due date of 12/22/2023.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023
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 12/13/2023 11:14 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: RIDGE GATE HAVEN
FACILITY NUMBER: 306001577

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/22/2023
Section Cited
CCR
8716

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(a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569. Based on record review, the licensee did not comply with the section cited above as the facility has a past due balance. This poses a potential risk to future persons in care.
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Owner stated that they will reach out to administrator and advise him to pay. Owner stated that Administrator will send to LPA via email proof of payment of balance by the assigned POC due date of 12/22/2023.
Type B
12/22/2023
Section Cited
CCR
87203

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All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. Based on observation, the licensee did not comply with the section cited above as the facility's fire extinguishers were last serviced on
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Owner stated that the facility will schedule the fire extinguishers to get serviced. Owner stated the Administrator will notify LPA via email with proof of scheduled fire extinguisher service by the assigned POC due date of 12/22/2023.
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7/28/2021. This poses a potential safety risk to future 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: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 12/13/2023 11:14 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: RIDGE GATE HAVEN
FACILITY NUMBER: 306001577

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/22/2023
Section Cited
CCR
87307(a)(2)(B)

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(B)No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway,unfinished attic, garage, storage area, shed or similar detached building. Based on LPA observations, the licensee did not comply with the section cited above as
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Owner stated that the room would be converted back into a bedroom for resident use by the assigned POC due date of 12/22/2023. LPA will conduct a follow-up visit to confirm the correction.
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one bedroom designated for resident use has been converted into a fitness room. This poses a potential personal rights risk to future persons in care.
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Type B
12/22/2023
Section Cited
HSC1569.618(c)(3)

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 (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. Based on record review, the licensee did not comply with the
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Owner stated Administrator will have staff CPR training scheduled. Owner stated Owner stated Administrator will notify LPA via email with proof of scheduled CPR trainings by POC due date of 12/22/2023.
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section cited above as none of the staff have a current CPR certification. This poses a potential safety risk 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: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3