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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603045
Report Date: 01/02/2025
Date Signed: 01/02/2025 12:03:02 PM

Document Has Been Signed on 01/02/2025 12:03 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MADELEINE'S SENIOR LIVINGFACILITY NUMBER:
374603045
ADMINISTRATOR/
DIRECTOR:		TEOFILO P MENDOZA JR.FACILITY TYPE:
740
ADDRESS:2880 WANEK RDTELEPHONE:
(760) 781-1027
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
01/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:11 AM
MET WITH:Elvira Sison, Administrator TIME VISIT/
INSPECTION COMPLETED:
12:11 PM
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On 01/02/25 at 9:11am Licensing Program Analyst (LPA) Javina George made an unannounced visit tot the facility to conduct a 1 year required visit/annual inspection. LPA was greeted and granted entry by Administrator Elvira Sison, where LPA explained the purpose of the visit. The facility is licensed to serve six (6) elderly residents, ages 60 and above. Five (5) of whom may be non ambulatory and one (1) bedridden, and resident in room #3. The facility has an approved hospice waiver for (6). There are currently (4) residents receiving hospice services. Below is a summary of what was observed during today’s inspection:

Infection Control: LPA George observed that the facility has an Infection Control Plan on file that was approved on 2/15/22. Facility staff were observed to demonstrate best practices in the facility to maintain a healthy environment for staff and residents such as proper hand hygiene and wearing masks. The facility is also taking the resident temperatures daily.

Physical Plant: LPA toured the interior and exterior of the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. The exits are not obstructed and that there is plenty of space for activities. There are no pools or bodies of water on the premises.

Records Review: Staff Records: LPA observed that there are sufficient staff present (2) to meet the needs of residents. LPA George additionally confirmed that there is an Administrator present with a valid certificate which expires on 07/13/26 for Administrator Elvira Sison. LPA George confirmed staff have criminal record clearance and were associated to the facility and have training to perform their required duties.

Resident Records: A review of the current residents to confirm that they have the required information present in their files, including Physician's Report, Admissions Agreement, and current Needs & Services Plan.

Tricia DanielsonTELEPHONE: (951) 202-5067
Javina GeorgeTELEPHONE: (951) 217-3970
DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2025
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: MADELEINE'S SENIOR LIVING
FACILITY NUMBER: 374603045
VISIT DATE: 01/02/2025
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Food Services: The kitchen and dining area to be maintained in a clean and healthful manner. Sufficient dishware and silverware were present for resident’s use. LPA George observed the facility to have the required amount of 7 day supply non-perishable and a two supply perishable food items.

Medication: Resident medication was observed to be locked inside a cabinet next the refrigerator inside of the kitchen. A review of medication revealed that the medication is being given as prescribed as evidenced by the Medication Authorization Record (MAR) and medication (bubble packs and or pill bottle).

Emergency Disaster Preparedness: The facility has an Emergency Disaster Plan on file and conducts disaster drills on a quarterly basis. The last drill was conducted on 09/08/24. The smoke and carbon monoxide detectors were tested and were found to be operable. The facility has one (1) fully charged fire extinguishers. There are no known guns or ammunition on the premises. The sharps and hazardous chemicals were observed to be locked and inaccessible to residents in care.

During today's visit LPA obtained a copy of the facility liability insurance which expires on 05/26/25. The facility annual fees that were due on or before 01/20/25, were observed to have been paid. Based on a review of facility documentation, the facility is to submit an updated copy of the Emergency Disaster Plan (LIC 610E) and facility sketch. The updated sketch is to include the cameras that are in the common areas as well as the staff quarters that are located inside the garage. The updated facility sketch and Emergency Disaster Plan are due to the department no later than Tuesday 01/07/25 by 5pm.

The facility was inspected and observed to be operating in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8), therefore no citations were issued during today's visit.

An exit interview was conducted and a copy of this report, were provided to Elvira Sison.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025
LIC809 (FAS) - (06/04)
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