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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004025
Report Date: 01/10/2025
Date Signed: 01/10/2025 12:03:47 PM

Document Has Been Signed on 01/10/2025 12:03 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PLAZA DE MADRIDFACILITY NUMBER:
306004025
ADMINISTRATOR/
DIRECTOR:
MARY GONZALESFACILITY TYPE:
735
ADDRESS:20120 PLAZA DE MADRIDTELEPHONE:
(562) 865-6095
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 4CENSUS: 4DATE:
01/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Mary Gonzales, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced visit at the facility for the purpose of conducting the required annual inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA Konishi met with Administrator, Mary Gonzales and explained the purpose for the visit.

The facility is licensed to serve a total of four (4) non-ambulatory developmentally disabled adults between the ages of 18-59, one restricted conditions, approved hospice waiver for one (1). Currently, there are four (4) clients in placement, there is a client who has a restricted health care condition. All clients residing at this facility receive case management services provided by Harbor Regional Center.

The following 5 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, and Personnel Records-Training.

During the visit LPA observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, has an Infection Control Plan. Facility has COVID-19 signage posted throughout the facility. Bathrooms have hand washing signs, soap, and paper towels. Facility Administrator is adhering to infection control requirements.

Operational Requirements: Emergency Fire Drill was conducted on 12/07/2024. Emergency Disaster/ Earthquake Drills was conducted on 12/07/2024. Facility Administrator is adhering to operational requirements.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2025
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PLAZA DE MADRID
FACILITY NUMBER: 306004025
VISIT DATE: 01/10/2025
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Physical Plant & Environment Safety: The facility is a single-story home located in a residential neighborhood and consists of: Four (4) client bedrooms, 2 bathrooms, living room, kitchen, activity area, medication, dining area, garage with laundry washing and drying machine, and backyard with shaded area. All client rooms were inspected and LPA observed client beds and the bedding for each bed were in good condition, adequate lighting provided, storage for client personal belongings was observed for each client. Each client bedrooms include all required furniture: a bed, chair, lamps, dressers, and sufficient lighting and closet space. The client’s bathroom is clean, sanitary and in a good working condition. Walls and floors were in good repair. Fireplace is securely closed and inaccessible to clients. Clean towels and bed linens are kept in the hallway closet. Bathroom is clean and operational. Toilets and water faucets worked properly. Showers were free of mold/mildew, had adequate lighting, and there are sufficient toiletries that are accessible to clients. Grab bars observed in the bathroom. Bathroom water temperature was tested as follow: water temperature bathroom #1 tested at 107.6 degrees F and bedroom #2 tested at 101.3 degrees F which is not within the required 105-120 degrees F. Facility temperature was comfortable and cool. LPA observed the facility to be clean and appropriately furnished with clear passageways inside and outside. All the sharp knives are locked in the kitchen cabinet and inaccessible to clients. Cleaning supplies are locked in the kitchen cabinet and inaccessible to clients. Carbon monoxide detectors were tested and in working condition. Fire extinguishers are in the kitchen and in the garage and both are fully charged and last inspected on 02/08/2024.

Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator, and Staff #1 (S1) to Staff #3 (S3). Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening, Employee Rights, Personnel Record on file. Administrator Certificate is pending. Administrator has required AIDS/HIV & TB training on file.

Due to time constraints, LPA will return at a later date to complete 7 more CARE Tool domains. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit Interview conducted and a copy of the report with appeal rights were provided to the Administrator, Maria Gonzales.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/10/2025 12:03 PM - It Cannot Be Edited


Created By: Daniel Konishi On 01/10/2025 at 11:49 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: 01/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA, Daniel Konishi measured client’s restroom hot water temperature read at in bedroom #1 at 107.6 degrees F and bathroom #2 at 101.3 degrees F which does not fall between the required 105 to 120 degree F which poses an potential health, safety, or personal rights risk to persons in care.
POC Due Date: 01/15/2025
Plan of Correction
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Administrator shall immediately adjust water temperature. Administrator to check water temperature at various different times throughout the day and maintain and submit a water temperature log to the LPA for the next 3 days to ensure that hot water temperature falls within 105 degree F and 120 degrees F. Administrator will provide a copy of the log to the LPA once water temperature falls within Title 22 guidelines.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:David Sicairos
LICENSING EVALUATOR NAME:Daniel Konishi
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2025


LIC809 (FAS) - (06/04)
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