<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006139
Report Date: 07/29/2022
Date Signed: 07/29/2022 01:25:26 PM


Document Has Been Signed on 07/29/2022 01:25 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:MAEDAUS CARE MANAGEMENT 1FACILITY NUMBER:
306006139
ADMINISTRATOR:SERNA, DANTEFACILITY TYPE:
740
ADDRESS:8556 BARR LANETELEPHONE:
(562) 394-3589
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:6CENSUS: 6DATE:
07/29/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:36 AM
MET WITH:Dante SernaTIME COMPLETED:
01:40 PM
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) Sean Haddad conducted this announced inspection for the purpose of conducting a pre-licensing inspection. LPA met with Administrator (AD) Dante Serna, discussed the purpose of the inspection, and toured the facility. Facility is to operate a Residential Care Facility for the Elderly. Application was submitted to Community Care Licensing on 02/07/2022. This is a change of ownership with persons in care.

During the inspection, LPA and AD observed the following: Structure. This is a one-story home. The home shares a plot with MAEDAUS CARE MANAGEMENT II 306006140. Facility is a 4-bedroom, 2-bathroom, 1 story house with no garage attached or detached. However, there is a garage attached to MAEDAUS CARE MANAGEMENT II 306006140 that is used for storage for both facilities. There is a back yard and a front yard with patio cover for the residents. Facility telephone number is (714) 643-9325. Resident Bedrooms. The 4 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Lamps, chairs, linens, and storage for each resident bedroom inspected. Staff Bedrooms. It is unclear if there is a staff bedroom, see below. Bathrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 107 to 109 F degrees. Linens & Hygiene Supplies. New linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. 2 days perishable and 7 days nonperishable food supply reviewed. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed and tested, including the smoke detector/carbon monoxide detector. Appliances. Stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the medicine cabinet. Toxins: observed locked under the sink and in the outdoor storage. Medication cabinet is locked. First-Aid Kit & Activity Supplies: observed and available. Resident & Staff Files. LPA reviewed 3 resident and 4 staff files. Fire clearance was approved by Orange County Fire Authority Inspector Chantelle Abadie on 05/17/2022. Backyard. Backyard is unobstructed. Backyard and front yard have shaded area for outdoor activities and sufficient seating for residents. Component III was completed with AD during today’s inspection.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: MAEDAUS CARE MANAGEMENT 1
FACILITY NUMBER: 306006139
VISIT DATE: 07/29/2022
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
26
27
28
29
30
31
32
Facility is currently operating under the liability insurance of current facility MJ HOME CARE (306005648). AD will switch liability insurance to new facility once the application is approved.

During the inspection, LPA and AD observed that the room that was used by the current facility as a staff bedroom is identified on the facility sketch as a storage room. The fire clearance that was approved on 05/17/2022 states “no bedroom for caretaker in building.” Per AD, the current facility has a fire clearance that allows that room to be used as a staff bedroom. LPA reviewed the current facility’s facility sketch and confirmed that room is listed as a staff bedroom. Per AD, the fire inspector did not clear that room to be used as a staff bedroom for the applicant. LPA advised AD that staff are not allowed to sleep at the facility other than in a fire cleared staff bedroom. LPA provided AD the following options:
(1) No staff sleep overnight at the facility, the facility provides care overnight via wake nightshift staff, and the facility maintains a capacity of 6 residents. AD may need to update the plan of operation to include these provisions.
(2) 1 resident room is changed to a staff bedroom, a staff may sleep at the facility overnight, and the facility capacity is lowered to 5. AD may need to obtain a new fire clearance and make other changes to the application.

AD stated that they will contact the fire inspector and explore if there are any changes that can be made that would allow the storage room to be fire cleared as a staff bedroom as it was previously was. LPA advised AD to work with CAB and the fire inspector to resolve the issue and to notify LPA once the facility is ready for inspection.

During the inspection, LPA explained the process of this application and about the post licensing inspection once the facility is licensed. AD was informed the items listed above must be completed for the facility to meet Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to AD.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2