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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005945
Report Date: 02/02/2024
Date Signed: 02/02/2024 11:41:39 AM

Document Has Been Signed on 02/02/2024 11:41 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 COUNTY ASC, 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: 2DATE:
02/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Elizabeth Maldonado - LicenseeTIME COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility to conduct an unannounced Required 1-Year Inspection. LPA was greeted and granted entry by Licensee Elizabeth Maldonado

The facility is a one-story home with three client bedrooms, two bathrooms, living room, dining room, kitchen, laundry room, staff room/bathroom, backyard and attached two car garage. Facility fire extinguishers were observed to be fully charged and serviced on 1/9/24 per the service tags. LPA did not observe any hazards or obstacles throughout the facility. Bedrooms had the necessary furnishings. LPA observed two rooms to be vacant. Hot water in both bathrooms measured at 110 degrees Fahrenheit and 105 degrees Fahrenheit. LPA issued a Technical Assistance advising Licensee to maintain water log. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients and will be stored and locked in the garage. Medication is locked in a cabinet in the hallway. Files are stored in the workstation near the living room and kitchen. LPA reviewed two of two client files, medication and P&I. Clients were observed to be away from the facility at day program and with family. LPA reviewed four staff files. Based on file review, LPA determined facility has been conducting disaster drills twice a year as opposed to quarterly. A deficiency is being issued on this day. Smoke and carbon monoxide detector tested operational.

LPA issued three Technical Violations for the following Regulations: Infection Control 85095.5(c), Personnel Records - Training 80066(a)(10) and Safeguards for Cash Resources, Personal Property and Valuables of Residents 80026(h)(1)(A) & 80026(h)(1)(B).

Based on the observations made during today's visit, one deficiency is being cited as per Title 22 Division 6 Chapter 2 of the California Code of Regulations. An exit interview was conducted with Licensee Elizabeth Maldonado, and a copy of this report, deficiency page, LIC9102s and appeal rights were provided.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2024
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 02/02/2024 11:41 AM - It Cannot Be Edited


Created By: Dwayne L Mason On 02/02/2024 at 10:59 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: MALDONADO FAMILY HOME
FACILITY NUMBER: 306005945

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2023. LPA noted drills were conducted in January 2023 and July 2023, but not during the second or fourth quarters of the year. This poses a potential safety risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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Licensee stated they have already conducted a drill in January of 2024. Licensee decided to select a date for the next disaster drill during Q2 2024. Licensee created a calendar date on their phone for a drill to be conducted on April 15, 2024. Licensee sent a screenshot of the scheduled disaster drill to the LPA via email. LPA cleared the deficiency during the inspection.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024


LIC809 (FAS) - (06/04)
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