<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004025
Report Date: 12/03/2022
Date Signed: 12/06/2022 08:51:24 AM

Document Has Been Signed on 12/06/2022 08:51 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PLAZA DE MADRIDFACILITY NUMBER:
306004025
ADMINISTRATOR:MARY GONZALESFACILITY TYPE:
735
ADDRESS:20120 PLAZA DE MADRIDTELEPHONE:
(562) 865-6095
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 4CENSUS: 4DATE:
12/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Administrator Mary GonzalezTIME COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Required 1- year visit focusing on COVID-19 Infection Control Practices. LPA met with DSP staff Adelia Gomez and explained the purpose of the visit. Administrator Mary Gonzales arrived shortly after. The facility currently serving three (3) level 4 developmentally disabled clients over the age of 60, and one (1) level 4 developmentally disabled client under 59 years old. Three (3) of the four (4) clients have restricted health conditions. The facility is licensed for four (4) non ambulatory developmentally disabled adults ages 18 to 59 years old. All clients are served by Harbor Regional Center.

The facility is a single-story home located on a residential cul-de-sac. LPA and Administrator Gonzales toured the facility which consist of an open yard, four (4) bedrooms, two (2) bathrooms, staff office, kitchen, living room, dining room, den/activity room, outdoor covered patio, and attached garage with laundry area. The last fire drill was conducted on 09-19-22.

LPA observed COVID-19 Infection Control screening and signs to be posted in the entrance, common areas, hallways, and bathrooms. Signs encouraging hand washing, cough/sneeze etiquette, and physical distancing were observed. LPA observed drawer in kitchen containing bleach, glass cleaner, toilet bowel cleaner and other chemicals to be unlocked and broken. LPA observed all client bedrooms to contain a bed, linen, dresser, chair, light, and sufficient closet space. LPA tested water in bathroom #1 at 106F degrees and bathroom #2 was tested at 109.2 F degrees which is within the required 105F-120F degrees. Lights were not working in bathroom#1. Per DSP Staff Gomez, the light went out this morning and reported it to management immediately. LPA observed PPE supply located in the garage. Facility has approved COVID-19 Mitigation Plan and staff were observed to be wearing surgical masks. LPA reviewed four (4) client medication records. Medications are documented and stored in a locked rolling cabinet located in the kitchen area. Staff and resident files were not reviewed during today’s visit.

Deficiencies cited on 809D

Exit interview was conducted with Administrator Gonzales. A copy of the report/ appeal rights were issued.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2022
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 4
Document Has Been Signed on 12/06/2022 08:51 AM - It Cannot Be Edited


Created By: Kimberly Ramirez On 12/03/2022 at 11:48 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PLAZA DE MADRID
FACILITY NUMBER: 306004025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, cabinet containing cleaning chemicals was unlocked and the lock was broken, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/17/2022
Plan of Correction
1
2
3
4
Administrator/Licensee will fix lock and send picture proof of lock and receipt of new lock. Staff moved all cleaning products in said cabinet to locked cabinet in patio area which is inaccessible to clients while LPA was present.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2022


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/06/2022 08:51 AM - It Cannot Be Edited


Created By: Kimberly Ramirez On 12/03/2022 at 11:48 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PLAZA DE MADRID
FACILITY NUMBER: 306004025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, light in bathroom #1 was not working, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2022
Plan of Correction
1
2
3
4
Administrator/Licensee will provide photo proof and receipt of correction. Per Administrator Gonzales clients will use bathroom #2 until light is fixed
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4