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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004025
Report Date: 12/29/2025
Date Signed: 12/29/2025 02:46:37 PM

Document Has Been Signed on 12/29/2025 02:46 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:
12/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:06 AM
MET WITH:Administrator-TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Elena Mallett conducted the required annual inspection. LPA arrived unannounced and met with Assistant Administrator, Archimedes Lopez. The purpose of the visit was explained. Assistant Administrator toured LPA around the facility and Administrator Mary Gonzalez joined shortly after and assisted with the rest of the visit. The facility is licensed to serve 4 developmentally disabled adults (4 Non-Ambulatory). The facility currently has 4 clients that are serviced through Regional Center. One client has a restricted health condition.

The facility is a single-story home located in a residential area in Cerritos, Ca. A tour of the facility includes living room, kitchen, TV/Activity room, 4 private client bedrooms, 2 bathrooms and a staff office. There is a shaded patio in the backyard for clients. The garage is used for laundry and storage of emergency supplies, cleaning supplies and extra bedding.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Facility maintains the required Infection Control Plan.

See 809-C

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 12/29/2025
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Physical Plant & Environment Safety: LPA toured facility. The facility is well maintained and halls and passage ways free from obstruction and debris. Clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. Extra linen was available for each client. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. The facility van is parked in the backyard to enable easy access for clients being transported to Day program and outings. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked cabinets and are inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. There are 2 fully charged fire extinguishers present. Client and Staff files are kept locked in cabinets. Water in both bathrooms measured within Title 22 requirements. All client rooms were observed to have the required bedding and furnishings. The combination smoke detector/carbon monoxide detectors were present throughout the house and were all operable. An operable, stand-alone carbon monoxide detector was observed in hall near client bedrooms.

Operational Requirements: Staff have proper training to meet the needs of the clients in care. Facility has an activity area furnished for outdoor use. Last fire/earthquake drill was conducted on 10/1/24. Facility has current Surety Bond.)

Staffing&Personnel Records-Training: There appears to be sufficient staffing at all times. LPA reviewed 4 staff files during today’s visit, files reviewed contained the following: Criminal Background Clearance, Health screening, current First-Aid/CPR and proof of annual training. Mary Gonzalez’s Administrator certificate expires on 12/29/26. There were no issues observed.

Client Rights-Information: Facility provides telephone landline and internet for the clients. Client rights posters and reporting posters are displayed within the facility.

Client Records-Incident Reports: Client files were readily available and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Ambulatory status, Medical Consent Needs & Services Plan and P&I ledger with current balances. LPA reviewed 4 client files with no issues.

See 809-C

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 12/29/2025
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Food Service: The kitchen was observed for the ability to prepare and serve food. The refrigerator was sanitary and provided area for proper food storage. Appliances in kitchen were operable. 2 days perishable and 7 days non-perishable food supply was present. Food for the client with the G tube there was food available and in sufficient supply. A sample menu was provided. Emergency food and water was present.

Health Related Service: Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. LPA reviewed 3 clients’ medications with no issues.

Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills. Last drill was conducted on 09/01/25. A full First Aid kit and Manual was observed.

Emergency Intervention: Clients at this facility do not need the use of restraints or de-escalation techniques.

LPA noted during plant tour that some incontinent supplies were stored in boxes in the outdoor, covered patio. LPA advised that indoor storage would provide better protection from weather.

LPA informed Administrator of overdue Licensing Fees for facility. Administrator stated fees were paid during visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during todays visit. Exit interview was held with Administrator Mary Gonzalez and a copy of this Licensing report was provided.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025
LIC809 (FAS) - (06/04)
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