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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881593
Report Date: 10/30/2024
Date Signed: 10/30/2024 10:23:44 AM

Document Has Been Signed on 10/30/2024 10:23 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
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:
10/30/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Estrella BuensucesoTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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Licensing Program Analysts, (LPAs) Armando Perez and Abdoulaye Zerbo made an announced visit to the facility for the purpose of conducting a pre-licensing inspection. LPAs met with applicants Estrella Buensuceso and Gretchen Pinlac who accompanied LPAs for the inspection. Applicants has submitted an application for four(4) ambulatory residents. On May 15, 2024, Riverside City Fire Department approved a fire clearance for the facility.

The facility is a one story home with 4 client bedrooms, 1 staff den room, 3 bathrooms, laundry room, living room, dining area, kitchen, and attached garage. LPAs observed clients’ bedrooms with the required bedding and furniture, such as, clean mattresses/linen, night stands, dressers, chairs, lighting, and emergency lighting. Client bathrooms and showers had clean appliances that were operating in safe and sanitary condition. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. The facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Chemicals and Sharps, such as knives and scissors, will be stored in a locked cabinet in the kitchen under the sink.

Client files, staff and facility files will be in a locked cabinet in the living room. Client medication will be centrally stored and locked in a separate cabinet in the living room as well. The facility has no pool or any bodies of water. There is a covered patio area with seating for all the clients. All passageways were free from obstruction. LPAs observed 1 charged fire extinguisher in the facility with the expiration date of May 7, 2025. The smoke detectors and carbon monoxide alarms were combined, hard wired and operational. LPAs observed a covered fireplace in the family area that appears to be inoperable. The facility does not have any known firearms and ammunition on the property. LPAs observed the required postings of the emergency disaster plan, resident personal rights, complaint procedures, employee rights, visitation rights, facility sketch, and the Long-Term Care Ombudsman poster. Facility contains emergency supplies and first aid kits with the required items.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MADISON HOME
FACILITY NUMBER: 331881593
VISIT DATE: 10/30/2024
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 The facility has working telephone for client use. LPAs observed Applicant's Administrator Certification with expiration of January 28, 2026 and a valid CPR certification on file with expiration date of September 18, 2026.

Applicant disclosed a vehicle will be accessible for transporting residents as needed. LPAs observed the vehicle to be clean with sufficient seating and have valid registration until September 2025.

LPAs observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. LPAs confirmed the Comp III orientation was completed on October 8th, 2024. LPAs determined the facility meets the operational requirements for licensure. The Pre-licensing inspection is complete and this facility has no issues or concerns. The facility has satisfied all requirements in accordance with Title 22, California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Applicants, Estrella Buensuceso and Gretchen Pinlac.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC809 (FAS) - (06/04)
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