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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003948
Report Date: 05/31/2022
Date Signed: 05/31/2022 11:41:05 AM

Document Has Been Signed on 05/31/2022 11:41 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MAPLEWOOD HOMEFACILITY NUMBER:
306003948
ADMINISTRATOR:OSCAR R. CACHUELAFACILITY TYPE:
735
ADDRESS:1910 N. MAPLEWOOD STREETTELEPHONE:
(714) 279-8171
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY: 5CENSUS: 5DATE:
05/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Administrator Hernand LiwanagTIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Shobhana Frank conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into the facility by Administrator Hernand Liwanag and explained the reason for the visit.

LPA Frank toured the facility. There are 5 residents residing in the facility and one active COVID-19 case as of 5/24/22 and resident is Isolated. On 5/30/22 resident was tested COVID positive. LPA observed 1 residents on site appeared clean and well taken care of, 1 resident is admitted due to weakness, 2 residents are at the day program. LPA observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed had ample soap/ sanitizer and appeared clean. Resident bedrooms appeared clean and sanitary and had all confirmed food supply: 2 day supply of perishables and 7 day supply of
non-perishable food is available for the number of residents present. Hygiene supplies and supply of linen
were observed in quantities for the number of residents in care. LPA observed locked areas for toxins and
hazardous items. Medication were observed locked in cabinet.
LPA observe the facility to be clean and in good repair.
LPA Frank reviewed : 1.) Emergency Disaster Plan (LIC610E); 2 ) LIC 9020A Client Roster; LIC 808)
Mitigation Plan and 3) Current Liability Insurance, Designation of Administrative Responsibility (LIC308) and
Personnel Report (LIC500);
Based on the observations made during today’s visit, no deficiencies are being cited in area inspected.
This report was discussed with the facility representative and a copy was provided.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Shobhana Frank
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2022
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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