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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881593
Report Date: 10/08/2024
Date Signed: 10/08/2024 09:46:16 AM

Document Has Been Signed on 10/08/2024 09:46 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:MADISON HOMEFACILITY NUMBER:
331881593
ADMINISTRATOR/
DIRECTOR:		BUENSUCESO, ESTRELLAFACILITY TYPE:
735
ADDRESS:948 CORNFLOWER DR.TELEPHONE:
(714) 718-2900
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY: 4CENSUS: DATE:
10/08/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Estrella Buensuceso, Gretchen PinlacTIME VISIT/
INSPECTION COMPLETED:
09:45 AM
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Facility Type: ARF
Application Type: Initial
Capacity: 4
Census (if any clients in care): 0
COMP II Participants: Estrella Buensuceso (applicant/licensee, administrator), Gretchen Pinlac (applicant/licensee)
Interview Method: microsoft teams

On 10/8/24, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Mirella Quaranta
LICENSING EVALUATOR NAME: Susan Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2024
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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