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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005945
Report Date: 02/24/2023
Date Signed: 02/24/2023 11:53:10 AM

Document Has Been Signed on 02/24/2023 11:53 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
ORANGE & INLAND A/SC, 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:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Elizabeth Maldonado, AdministratorTIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into the facility by care staff and LPA explained the nature of the visit. Elizabeth Maldonado, Administrator arrived shortly after and met with LPA.
LPA Martinez accompanied by care staff began the tour of the inside and outside of the facility. There are four clients in care and no covid cases in the facility. Upon entry LPA observed one client in dinning table. Shortly after two clients arrived from being out in the community. All clients appeared to be clean and well taken care of. Facility has a sign-in procedure in place and LPA was checked in with temperature check. LPA observed required Department posting and covid precautionary postings in place at the facility. LPA observed the Emergency Disaster Plan posted at the facility. Facility has a Mitigation Plan in place with the department. There is a minimum of one week of non-perishables and two days of perishables foods available. Facility was observed to have a supply of emergency food and water in the facility. The facility has hygiene, cleaning and disinfectant supplies. Personal protective equipment (PPE) was observed to be available at the facility. All bathrooms were observed to be supplied with soap, toilet paper and paper towels. LPA toured the client’s bedrooms, all bedrooms observed to have all required components. Facility has a secure locked medication storage and has a 30 day supply of medication for clients. LPA observed the outside to the facility and observed seating area for clients use.

Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the Administrator and a copy of this report was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2023
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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