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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003680
Report Date: 04/28/2022
Date Signed: 04/28/2022 12:09:35 PM

Document Has Been Signed on 04/28/2022 12:09 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:MAX MAXIM SENIOR CAREFACILITY NUMBER:
306003680
ADMINISTRATOR:MARIANA MAXIMFACILITY TYPE:
740
ADDRESS:10448 NIGHTINGALE AVENUETELEPHONE:
(714) 213-3045
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
04/28/2022
TYPE OF VISIT:CollateralANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Michelle KelloggTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Michelle Reed and Jenifer Tirre arrived at the facility to conduct a case management in regards to Complaint #22-NP-20220422135229. Upon arrival, LPA met with Administrator Donna Lalap and Staff Michelle Kellogg. Staff Olimpia Lang was also present. Records for Resident #1 were reviewed and copies were made. The following records were obtained; Identification and Emergency Information, Preplacement Appraisal, Appraisal Needs and Service Plan, Admission Agreement and Discharge papers from hospital at time of arrival. Home Health documents were present but blank.

Resident #1 is not present at the facility. She is in the hospital and is expected to return pending reappraisal.

During the visit, LPA's noted that Michelle Kellogg and Donna Lalap are not associated to the facility.

The following documents were requested and will be sent to LPA Reed by 4/29/22.

1) Management Agreement
2) Lease Back Agreement
3) LIC500
4) Administrator Paperwork for Donna Lalap

See LIC809D for cited deficiency.

An exit interview was conducted and a copy of this report was provided to Administrator Olimpia Lang.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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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Document Has Been Signed on 04/28/2022 12:09 PM - It Cannot Be Edited


Created By: Michelle Reed On 04/28/2022 at 10:07 AM
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: MAX MAXIM SENIOR CARE
FACILITY NUMBER: 306003680

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2022
Section Cited
CCR
87355(e)

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Criminal Record Clearance-All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department or request a transfer of a criminal record clearance.
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Licensee will immediately associate Michelle Kellogg and Donna Lalep to the facility.
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This requirement was not met as evidenced by:

Staff Michelle Kellogg and Donna Lalap are not associated to the facility.
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HSC


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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:Sheila Santos
LICENSING EVALUATOR NAME:Michelle Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022


LIC809 (FAS) - (06/04)
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