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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004025
Report Date: 01/09/2024
Date Signed: 01/09/2024 11:26:01 AM

Document Has Been Signed on 01/09/2024 11:26 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, 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:
01/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:21 AM
MET WITH:Administrator Mary GonzalesTIME COMPLETED:
11:40 AM
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On 1/09/24 at 8:21 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to Plaza De Madrid. Upon arrival LPA was greeted by Direct Support Professional (DSP) Sheryll Francisco who contacted the Administrator. The Administrators Archimedes Lopez and Mirafy Lopez arrived at 8: 40 am and LPA explained the reason for the visit. At 9:35 am Administrator Mary Gonzalez arrived at the home. This home is licensed to serve (4) non-ambulatory developmentally disabled adults ages 18 through 59, Restricted health condition. The home is vendored by Harbor Regional Center. There were (4) clients in care during the time of the visit. The last emergency disaster/fire drill was conducted on 12/07/23. The Administrator Certificate expires on 12/29/2024 #6004808735. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (4) staff files, (4) client files, medications, and medication administration records for (4) clients and P&I.

This home contains 4 bedrooms, 2 bathrooms, living room, office, kitchen, dining room, receiving area with fireplace, and an attached garage. LPA toured the physical plant with the Administrator. and observed all (4) client bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The two bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, shower chair, and bathmat. The temperature measured at 108.5*F-109.5*F respectively which meet title 22 guidelines. The smoke detectors were battery operated, tested, and observed to be working properly. The carbon monoxide detector was tested and functioning properly. There were (1) fire extinguishers located in kitchen fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans. The sharps and toxins were locked and secured in kitchen cabinets. The pantry was well stocked with canned goods, pasta, cereals, and contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the home.
(Report continued on LIC809C.)
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PLAZA DE MADRID
FACILITY NUMBER: 306004025
VISIT DATE: 01/09/2024
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The outdoor grounds were toured and inspected, and the patio was well maintained with a shaded seating area accessible for client use. The garage contained a working washer and dryer, with cabinetry that contained emergency supply kits, bottled water, toiletries, personal care supplies, PPE supplies, food supplies, toxins and cleaning agents stored locked and inaccessible to the clients.

The receiving area contained a non-working fireplace contained a covered screen so that it was inaccessible to the clients.

The notifications and postings: California Labor Laws, Emergency Disaster Plan, personal rights, facility license, business license, medical emergency information, let-us-know licensing contact information, consumer grievance, support services, community resources and client activity schedule.

Exit interview conducted with Administrators Archimedes Lopez, Mirafy Lopez and Mary Gonzalez a copy of this report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC809 (FAS) - (06/04)
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