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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004025
Report Date: 01/14/2025
Date Signed: 01/14/2025 03:27:27 PM

Document Has Been Signed on 01/14/2025 03:27 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:
01/14/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Mary Gonzales, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with S4 and the purpose of the visit was discussed. Administrator, Mary Gonzales arrived shortly after and the purpose of the visit was discussed.
The initial annual visit was conducted on 01/10/2025. During the initial visit the following five (5) Compliance and Regulatory Enforcement (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, and Personnel Records-Training.

During today’s annual visit, the following seven (7) Compliance and Regulatory Enforcement (CARE) tool domains were observed and reviewed: Client Rights-Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.



Client Rights-Information: Facility does not have any clients requiring postural supports. Client personal rights and House Rules are posted. Per Facility Administrator, facility provides wi-fi services to all clients.

Client Records-Incident Reports: LPA reviewed Client files for Client #1 (C1) through Client #4 (C4). Client files are maintained at the facility and have the following documents in their files - Admission Agreements, Emergency and Identification Information, Face sheet, Physician's Report (including T.B and Ambulatory Status), Weight log, Client Medication Destruction Record, Appraisal Needs and Services Plan, Functional Capabilities Assessment, Client Personal Property, Client Cash Resources, and Clients Personal Rights. LPA also reviewed all client's P & I.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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: 01/14/2025
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Food Service: The facility has sufficient food supplies of 2-day perishable and a week of non-perishable items. The food is properly stored in the refrigerator (clean and well-maintained). There are no clients with special diets residing at this facility. Pesticides and other similar toxic substances are stored away from the food, utensils, kitchen equipment, and food preparation area. Cleaning supplies are stored and kept away from food supplies. Kitchen is kept clean. LPA observed the Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

Health Related Services The medications are centrally stored and in their original containers. LPA reviewed medication for C1 through C4. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Physician‘s Orders were reviewed in client files. Medications are bubble packed and delivered monthly. First aid kit was observed and has all required items.

Incidental Medical Services: Based on record review and staff interview, there are clients under restricted health conditions and proper staff training for restricted health conditions are in file.

Disaster Preparedness: The facility has an Emergency Disaster Plan readily accessible.

Emergency Intervention: The facility does not use any restraint on clients.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed during the visit. Exit interview held and a copy of the report was provided to the Administrator, Mary Gonzales.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC809 (FAS) - (06/04)
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