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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006139
Report Date: 08/26/2022
Date Signed: 08/26/2022 09:30:27 AM


Document Has Been Signed on 08/26/2022 09:30 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
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:
08/26/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Dante SernaTIME COMPLETED:
09:45 AM
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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. This is the second pre-licensing inspection. Please see LIC809 dated 07/29/2022.

After the initial pre-licensing inspection, AD explored the options available, chose to move forward with Option 1 below, and submitted an updated plan of operation to include the required provisions.

“(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.”

During today’s inspection, LPA and AD inspected the facility and observed the room marked as a storage room on the floor plan has been cleared of room furniture, including the bed. LPA confirmed with AD that staff will not be sleeping overnight in this room. LPA reviewed the updated portions of the plan of operation and confirmed that the facility will provide care overnight via wake nightshift staff. The issue noted during the initial pre-licensing inspection has now been addressed.

LPA explained the process of this application and about the post licensing inspection once the facility is licensed. AD was informed today that the facility is ready for licensure and final approval will be processed by the CAB supervisor in Sacramento. Component III was completed with AD during the initial pre-licensing inspection. 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: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2022
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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