306005666-2-23-2022-22-AS-PVEZ-CBWQEF-20220223110616

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005666
Report Date: 02/23/2022
Date Signed: 02/23/2022 11:06:24 AM

Document Has Been Signed on 02/23/2022 11:06 AM - 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:	MADISON SENIOR CARE		FACILITY NUMBER:	306005666
ADMINISTRATOR:	RAMIREZ, BREANNA		FACILITY TYPE:	740
ADDRESS:	3083 MADISON AVENUE		TELEPHONE:	(714) 957-1148
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY:	6	CENSUS: 4	DATE:	02/23/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Breanna Ramirez - Administrator		TIME COMPLETED:	11:10 AM

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) Patricia Velazquez conducted an unannounced visit to Madison Senior Home. The purpose of today's visit was to conduct a Required 1 Year inspection. LPA Velazquez was allowed entry into the facility and met with Caregiver Sonia Garcia. Caregiver Adalila Rodriguez was also present. Administrator (AD) Breanna Ramirez arrived later to assist with the visit. The facility is licensed for 6 non-ambulatory residents. The facility also has an approved hospice waiver for 5 residents. There are currently 4 residents living in the facility. The last emergency disaster drill was conducted on November 4, 2021. LPA Velazquez informed AD Ramirez that the facility annual fees were not current as of February 16, 2022. LPA also provided AD with a copy of the Facility Transaction History that included a PIN to facilitate online payment of fees. AD Ramirez provided proof of payment of annual fees during this visit. At 9:54 AM LPA Velazquez conducted a tour of the physical plant along with Caregiver Garcia and then with AD Ramirez. The 1 story home consists of 5 resident bedrooms with 2 bathrooms and a Murphy bed for staff use. The 4 residents in the facility appeared well-groomed and well cared-for. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. LPA Velazquez observed bed rails on one of the resident beds. LPA was informed that resident was receiving hospice services. LPA Velazquez observed one of the resident bedrooms is having the flooring replaced. LPA was informed the floor installation will be completed today. Resident bath towels and personal hygiene supplies were adequately stocked. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew and a non-skid surface or mat was in place. LPA Velazquez tested the hot water temperature in the resident bathrooms and the temperature measured at 118.5 degrees Fahrenheit in the first bathroom and at 120.0 degrees Fahrenheit in the second bathroom. LPA Velazquez informed AD Ramirez regarding the hot water temperature and advised the temperature be adjusted so that it does not exceed 120 degrees Fahrenheit. LPA Velazquez inspected the kitchen along with AD Ramirez. Perishable and non-perishable food supply was checked and adequately

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MADISON SENIOR CARE	FACILITY NUMBER: 306005666
	VISIT DATE: 02/23/2022

NARRATIVE

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stocked at the time of the visit. The fire extinguishers were fully charged. The smoke and carbon monoxide detectors are hardwired were tested and found to be operational. Toxins, sharps, and medications were locked and inaccessible to residents. First Aid kit was checked and found to be in order. The facility did not have a First Aid manual and LPA Velazquez advised AD Ramirez to obtain an updated First Aid manual.

LPA Velazquez along with AD Ramirez toured the outside grounds and no bodies of water were observed. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards and the exit gates were operational. The auditory alarms were noted to be in operating condition. There were no security bars or weapons on the premises.

No resident or staff files were reviewed during this inspection. LPA Velazquez informed AD Ramirez to ensure a written physician's order for bed rails indicating the need is present in a resident's file pursuant to Title 22 Regulation Section 87608 Postural Supports.

There were no deficiencies issued during this Required 1 Year inspection. An exit interview was conducted with Administrator Breanna Ramirez and a copy of this report was provided at the time of this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

LIC809 (FAS) - (06/04)

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