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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004339
Report Date: 03/20/2023
Date Signed: 03/20/2023 01:15:25 PM

Document Has Been Signed on 03/20/2023 01:15 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PLAZA DE MADRID (NAPA)FACILITY NUMBER:
306004339
ADMINISTRATOR:ARCHIMEDES LOPEZFACILITY TYPE:
735
ADDRESS:17319 NAPA CIRCLETELEPHONE:
(562) 924-4394
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 3CENSUS: 2DATE:
03/20/2023
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator Archimedes LopezTIME COMPLETED:
01:45 PM
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On 3/20/2023 at 8:30 a.m., Licensing Program Analyst(s) (LPA) Jewel Baptiste conducted an unannounced annual visit at the facility using the CARE tool. LPA Baptiste met with Archimedes Lopez Administrator and explained the reason for the visit.

The facility is licensed to serve 3 non-ambulatory developmentally disabled adults with restricted health conditions. The facility is vendored through Harbor Regional Center. The facility is a single-story home, located in a residential area. It consists of; an administrator office area, kitchen, living room, family room, dining room, conference/receiving area, 3 resident bedrooms, 2 resident bathrooms, a garage, a front yard and backyard.

LPA Baptiste conducted a tour of the facility with Administrator Lopez and observed the following: Facility is in clean and good repair indoors and outdoors. Kitchen is clean, sharps were locked in the top cabinet. Sufficient food supplies were observed, at least 2 days of perishables and 7 days of non-perishables. (3) Resident's bedrooms were observed with sufficient lighting, furniture, and bedding supplies. (2) Resident's bathrooms were observed in working condition with grab bars, and water temperature was tested between 116.7 - 116.9 which is within the required 105-120 degrees F. Dining room, living room, and Conference/receiving were observed with sufficient sitting area. Smoke/Carbon monoxide detectors were tested and in working condition. Backyard was observed with covered sitting area. (CONTINUED LIC 809C)
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2023
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 (NAPA)
FACILITY NUMBER: 306004339
VISIT DATE: 03/20/2023
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The facility does not have any large body of water. Cleaning supplies are maintained in the kitchen, locked and inaccessible to the residents. Last emergency drill was conducted on 1/04/23. LPA Baptiste reviewed medication and files for 2 residents. Each resident file reviewed have all the required documentation. Staff files were reviewed for (4) staff and it have all the required documentation. An administrator certificate was reviewed for Archimedes Lopez #6052462735 exp: 6/03/23.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided to Administrator.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023
LIC809 (FAS) - (06/04)
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