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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005666
Report Date: 02/24/2025
Date Signed: 02/24/2025 01:47:52 PM

Document Has Been Signed on 02/24/2025 01:47 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 SENIOR CAREFACILITY NUMBER:
306005666
ADMINISTRATOR/
DIRECTOR:		RAMIREZ, BREANNAFACILITY TYPE:
740
ADDRESS:3083 MADISON AVENUETELEPHONE:
(714) 957-1148
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 6DATE:
02/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:06 PM
MET WITH:Breanna RamirezTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit and was greeted and granted entry by Caregiver Sonia Garcia. Administrator, Brianna Ramirez, joined the visit shortly after.
For today’s visit, LPA observed a total of 6 residents in care and 2 staff members on duty.
LPA observed the Administrator's Certificate for facility AD Breanna Ramirez which expires on 02/12/2025. LPA Haddadin toured the interior and exterior portions of the facility with (AD). The facility is a single level structure with five bedrooms and two restrooms and is licensed for 6 non-ambulatory residents, of which 5 may be on hospice and 0 bedridden.

LPA and AD tested smoke detectors/carbon monoxide in common areas and bedrooms; all tested and were operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably.

LPA observed fire extinguisher mounted in kitchen and garage areas with last inspection date of on July 29th, 2024. Upon review of record, emergency drill log indicated that the last drill was conducted in January of 2025.


LPA observed sharps sand knives locked in the kitchen and are inaccessible to residents in care. However. Medication is also locked in and secured in cabinet located in the kitchen.
Restrooms toilets and water faucets were also observed to be operational. Grab bars were secure, and showers were observed to be free of mold/mildew. Water temperature measured between at 117.6 degrees Fahrenheit and 118.9 degrees Fahrenheit. LPAs and AD toured the backyard of the facility and observed a shaded seating area for residents’ enjoyment. LPA checked emergency exits to be free of obstacles.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2025
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: MADISON SENIOR CARE
FACILITY NUMBER: 306005666
VISIT DATE: 02/24/2025
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LPA observed required department postings displayed on the wall of facility. LPA observed the minimum of one week of non-perishables foods and two days of perishables foods available. LPA reviewed two residents’ and two staff files and observed they all had the required documentation.

Based on the observations made during today’s inspection, NO deficiencies is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was provided to AD at end of inspection.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
LIC809 (FAS) - (06/04)
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