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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005407
Report Date: 06/12/2024
Date Signed: 06/12/2024 01:31:33 PM


Document Has Been Signed on 06/12/2024 01:31 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:MAISON FOR MOMFACILITY NUMBER:
306005407
ADMINISTRATOR:LUDINOT NIC, YAMASHIRO SHEFACILITY TYPE:
740
ADDRESS:804 W BRENTWOOD AVENUETELEPHONE:
(310) 994-9181
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY:6CENSUS: 6DATE:
06/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Shelly Yamashiro, AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPA was greeted and granted entry by facility caregiving staff after explaining the purpose of the visit. Facility administrator Shelly Yamashiro was notified by telephone and arrived later to assist.

During the inspection, LPA and facility staff conducted a tour of the physical plant and observed the following: The facility is a one story home with two private rooms, two shared room and one staff room in addition to the facility's common living areas. All resident bedrooms have the required furnishings. LPA observed all beds have linens and blankets. The backyard has a shaded area and the routes of egress are free of clutter and obstructions. There are currently six residents admitted to the facility with two residents receiving hospice care. Residents are observed to be clean and appear well taken care of. Bathrooms faucets and toilets were operational. Water temperature was verified to be within acceptable range. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required. Combined smoke and carbon monoxide detectors tested operational. Fire extinguisher present is observed to be fully charged with up-to-date maintenance. During the tour of the physical plant, potentially dangerous items such as bleach and insecticide were observed to be accessible and later secured by staff, resulting in deficiency being cited. The medication central storage was also observed to be secure and reviewed for accuracy during the visit. LPA reviewed six resident files and seven staff files as well as conducted two staff and two resident interviews.

Based on the observations made during today’s inspection, one type A deficiency is being cited per Title 22 Division 6 of the California Code of Regulations along with three technical advisory notes. An exit interview was conducted, and a copy of this report along with appeal rights was left at the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
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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Document Has Been Signed on 06/12/2024 01:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: MAISON FOR MOM
FACILITY NUMBER: 306005407

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation conducted during the tour of the physical, the licensee did not comply with the section cited above as bleach, supplements and insecticide were observed to be potentially accessible in a kitchen cabinet, bathroom cabinet as well as in the facility's backyard. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2024
Plan of Correction
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Dangerous items were secured or made inaccessible during the facility visit. Citation cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
LIC809 (FAS) - (06/04)
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