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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004711
Report Date: 07/26/2024
Date Signed: 07/26/2024 01:19:16 PM


Document Has Been Signed on 07/26/2024 01:19 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:MADISON GUEST HOMEFACILITY NUMBER:
306004711
ADMINISTRATOR:CELSO C. LAPINIDFACILITY TYPE:
740
ADDRESS:219 E. MADISON AVENUETELEPHONE:
(714) 646-9364
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY:6CENSUS: 6DATE:
07/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Caregiver, Arlene Cornejo TIME COMPLETED:
01:25 PM
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On 7/26/2024, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA was greeted and granted entry by Caregiver, Dennis Cornejo who was informed of the purpose of the visit. Caregiver, Arlene Cornejo called Administrator, Celso Lapinid and informed them of LPA's visit. The facility has a fire clearance for six (6) non-ambulatory elderly residents, of which one (1) may be bedridden. The facility also has an approved hospice waiver for four (4) and LPA was informed there are currently three (3) residents receiving hospice services at the facility.

LPA toured the facility with Caregiver Arlene and observed the facility is made up of a one-story home with six (6) resident bedrooms, three (3) bathrooms, a staff room, kitchen, dining room, living room and attached garage. During the tour, Caregiver Dennis tested three (3) smoke alarms/carbon monoxide detectors and LPA observed them to be operational. LPA also observed charged fire extinguishers mounted throughout the facility. LPA toured the kitchen and observed food was stored in a safe and healthful manner. The facility had more than a 2-day supply of perishable foods and 7-day supply of non-perishable food items. Medications are secured in a locked kitchen cabinet. Indoor and outdoor passageways were free of obstruction. The facility has an outdoor shaded seating area for resident leisure. No bodies of water were observed on the premises. Resident bedrooms had the required furniture and lighting. Bathrooms had grab bars near the toilets and in the showers. LPA also observed the facility has additional clean linens, towels, personal protective equipment, and incontinent supplies stored in a hallway closet. LPA reviewed random staff and resident files. Resident files reviewed had signed admission agreements and updated physician reports. Staff files reviewed had a criminal record clearance and a valid first aid/CPR certification.

During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted where this report was reviewed and provided to Caregiver Arlene.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: 951-248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024
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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