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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004339
Report Date: 03/03/2025
Date Signed: 03/03/2025 04:21:25 PM

Document Has Been Signed on 03/03/2025 04:21 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 MADRID (NAPA)FACILITY NUMBER:
306004339
ADMINISTRATOR/
DIRECTOR:		ARCHIMEDES LOPEZFACILITY TYPE:
735
ADDRESS:17319 NAPA CIRCLETELEPHONE:
(562) 924-4394
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 3CENSUS: 3DATE:
03/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Archimedes Lopez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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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 Archimedes Lopez and explained the purpose for the visit.

This home is licensed to serve three (3) Developmentally Disabled Adults, (3) non-Ambulatory adults ages 18 through 59 and vendor is Harbor Regional Center. There were three (3) clients in care during the time of this visit.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical Services, Disaster Preparedness, and Emergency Intervention.

During the visit LPA observed the following:

Infection Control: The facility has an infection control plan in place and the 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: Facility Administrator is adhering to operational requirements. Facility ensures the clients are given the opportunity to attend and participate in community activities.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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 (NAPA)
FACILITY NUMBER: 306004339
VISIT DATE: 03/03/2025
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Physical Plant & Environment Safety: The facility is a single-story home located in a residential neighborhood and consists of three (3) client bedrooms, 2 bathrooms, living room, kitchen, activity area, dining area, office area, and garage. 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. Clean towels and new bed linens are currently in bathroom #1. 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 tested at 112.6 and 112.4 degrees F which is 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 drawers and inaccessible to clients. Cleaning supplies are locked underneath the kitchen sink and inaccessible to clients. Fireplace is secure 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 02/06/2025.

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 #4 (S4). 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 expires on 06/3/2025. Administrator has required HIV & TB training on file.

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.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2025
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 (NAPA)
FACILITY NUMBER: 306004339
VISIT DATE: 03/03/2025
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Client Records-Incident Reports: LPA reviewed Client files for Client #1 (C1) through Client #3 (C3). Client files are maintained at the facility and have the following documents in their files - Admission Agreements, Face sheet, Emergency and Identification Information form, Physician's Report (including T.B and Ambulatory Status), Immunization records, Client Medication Destruction Record, Individual Program Plan (IPP), Functional Capabilities Assessment, Client Personal Property, Client Cash Resources, and Clients Personal Rights.

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. 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 C3. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubble packed and delivered monthly. First aid kit was observed and has all required items. Facility staff provide transportation to medical and dental appointments.

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 Fire and Disaster Drill was conducted on 1/15/2025.

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

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

DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2025
LIC809 (FAS) - (06/04)
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