306005407-5-13-2022-22-AS-JCHO-CEE2HM-20220513172459

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005407
Report Date: 05/13/2022
Date Signed: 05/13/2022 05:25:09 PM

Document Has Been Signed on 05/13/2022 05:25 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	MAISON FOR MOM		FACILITY NUMBER:	306005407
ADMINISTRATOR:	LUDINOT NIC, YAMASHIRO SHE		FACILITY TYPE:	740
ADDRESS:	804 W BRENTWOOD AVENUE		TELEPHONE:	(310) 994-9181
CITY:	ORANGE	STATE: CA	ZIP CODE:	92865
CAPACITY:	6	CENSUS: 5	DATE:	05/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:05 PM
MET WITH:	Nicolas Oudinot, Arlene Joyce Cornejo		TIME COMPLETED:	05:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit to conduct the required annual (mitigation) inspection. LPA was greeted by Caregiver Marcalfred Dimaano who was then washing the car with Caregiver Joel Evangelista in front of the garage. Caregiver Dimaano instructed LPA to go inside the facility to meet with Caregiver Arlene Joyce Cornejo. LPA was greeted and granted entry by Caregiver Cornejo after completing the Coronavirus 2019 (COVID-19) screening procedure. LPA stated the purpose of the visit and began the tour of the facility. The Administrator (Admin) Nicolas Oudinot joined around 3:55 pm. The facility is a single level structure and licensed for six non-ambulatory residents and has an approved waiver for six hospice residents. As of today, there are two residents in hospice care. LPA observed two staff on duty and four residents resting in the living room and one resident sleeping in their bedroom. LPA observed the required department postings at the front door and all around the facility as well as hand washing signs in the restroom. LPA observed all restrooms had ample soap/sanitizer and appeared clean. Bathrooms were provided with grab bars, but a non-skid floor mat was not observed. Residents' bedrooms appeared clean and sanitary and had all required components. Smoke detectors, carbon monoxide, and auditory exit alarms were tested and operational. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Sharp items were inaccessible to the residents in care, however the medications were accessible in Bedrooms #1 to #3. LPA observed the following: two prescription topical creams and 1 Isopropyl alcohol in Bedroom #1; two prescription topical creams and 1 bottle of Ibuprofen in Bedroom #2; a nail file, prescription eye drop, and 1 large blue scissor in Bedroom #3. All of the items were removed during the visit. In addition, LPA observed that the garage door did not lock from the inside of the facility. LPA requested to replace the door handle. Fire extinguisher was mounted and charged.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MAISON FOR MOM	FACILITY NUMBER: 306005407
	VISIT DATE: 05/13/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

For the exterior portion, facility had patio furniture under ample shading. LPA observed the emergency disaster and evacuation plans. Facility does have back-up emergency food and water supply and has a 30 day supply of PPEs. The First Aid Kit met all the required elements except for a manual.

LPA discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

LPA reviewed the COVID-19 mitigation plan of the facility. No deficiency cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit, and the licensee will follow-up with the corrections. An exit interview was conducted with Caregiver Arlene Joyce Cornejo, and a copy of this report was provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3