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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005945
Report Date: 03/14/2022
Date Signed: 03/14/2022 12:44:37 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/14/2022 12:44 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:MALDONADO FAMILY HOMEFACILITY NUMBER:
306005945
ADMINISTRATOR:UJKIC, VICTORFACILITY TYPE:
735
ADDRESS:17939 ASH STTELEPHONE:
(714) 622-4316
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 4DATE:
03/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Elizabeth Maldonado, LicenseeTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection. LPA arrived at facility, was greeted and granted entry by caregiver after explaining the purpose of the visit. Caregiver called Licensee Elizabeth Maldonada to notify her of the visit.

At approximately 9:55am, LPA accompanied by caregiver toured the inside and outside of the facility. There are currently four (4) clients in care. At the time of the visit, three (3) clients are present and the fourth one is at a day program. Clients are observed to be relaxing in their bedrooms or in the common areas and appear well taken care of. The bedrooms observed include all necessary components. Facility appears to be clean, sanitary and free of odors in all areas inspected. Most cleaning supplies and other toxic substances are located in a locked cabinet in the garage, which is itself unlocked. Laundry detergent and bleach are stored on a shelf next to the washing machines.
LPA observed the facility has COVID-19 Precautions posters and required department postings as well as hand washing signs. Facility has an adequate supply of PPE and emergency supplies. A LIC808 Mitigation has been submitted and approved by LPA Sean Haddad on 04/27/2021.
LPA observed a sufficient supply of food and water. A 30-day supply of medication is stored and locked. LPA toured the outside of the facility. Outdoor furniture is present for the clients' enjoyment and outside space is free of clutter and debris. A hot tub is present in the backyard but is not in use and empty.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. A Technical Advisory is being issued. This report was reviewed with facility representative and a copy of this report was provided and left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2022
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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