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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004339
Report Date: 03/12/2024
Date Signed: 03/12/2024 04:13:21 PM

Document Has Been Signed on 03/12/2024 04:13 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: 3DATE:
03/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Archimedes LopezTIME COMPLETED:
04:27 PM
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On 3/12/2024 at 2:00 p.m., Licensing Program Analyst(s) (LPA) Jewel Baptiste conducted an unannounced annual visit at the facility listed above. Upon arrival LPA observed no one was home. LPA contacted Mary Gonzales Licensee. At 2:26 pm Administrator Archimedes Lopez arrived. LPA Baptiste met with Archimedes Lopez 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 a level 4 and negotiable and the vendor is Harbor Regional Center. There were (0) clients in care during the time of this visit, the (3) clients were at the day program. The last emergency disaster/fire drill was conducted on 1/10/2024. The Administrator Certificate expires on 6/03/2025 #6052462735. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (3) staff files, (3) client files, medications, and medication administration records for (3) clients and P&I.

The facility is a single-story home, located in a residential area. It consists of; an administrator office area, kitchen, living room with covered fireplace, 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 clean and good repair indoors and outdoors. Kitchen is clean, sharps were locked in the top cabinet and toxins is locked in bottom 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. The water temperature was tested between 113.1 - 113.9 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.

Report continued on 809c
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2024
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 (NAPA)
FACILITY NUMBER: 306004339
VISIT DATE: 03/12/2024
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The facility does not have any large body of water. The back yard consists of 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, and toxins and cleaning agents stored locked and inaccessible to the clients.

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 the Administrator.

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

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC809 (FAS) - (06/04)
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