507005097-7-19-2021-27-AS-CYAG-C53VHE-20210719162701

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507005097
Report Date: 05/24/2021
Date Signed: 07/19/2021 04:27:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	MALONZO ELDERCARE, INC.		FACILITY NUMBER:	507005097
ADMINISTRATOR:	MALONZO, CLEOFE S.		FACILITY TYPE:	740
ADDRESS:	1709 ST. CHARLOTTE LANE		TELEPHONE:	(949) 378-1285
CITY:	MODESTO	STATE: CA	ZIP CODE:	95358
CAPACITY:	5	CENSUS: 4	DATE:	05/24/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Cleofe Malonzo		TIME COMPLETED:	12:30 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	Unannounced annual visit made out to this facility on 05/24/2021 by LPA Yang who was met by the facility designated Administrator, Cleofe Malonzo, and was briefly interviewed. Current census was 4 residents. This facility is vendorized through Valley Mountain Regional Center to accept and retain residents in a Level 4C setting. Tour of this facility was conducted. Fire extinguisher, located in kitchen area, was observed to have been annually purchased on 03/21/2021. Kitchen area was toured. Cabinets and drawers were reviewed to make sure that they were functional and in good repair at this time. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities. Drawers containing knives and cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Common areas intended for resident use were observed to be furnished and maintained able to meet the needs of the residents at this time. Resident rooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Resident restroom was toured. Grab bars and non skid mats were observed to be present and in good repair at this time. Hot water temperature was taken and measured to make sure that it was within the allowed range of 105-120 degrees. Medication cabinet was observed to be locked and made inaccessible to the residents at this time. A review of the medication and Medication Administration Record was conducted. Resident medications were observed to be prepackaged and sorted in blister packs from the responsible pharmacy with a 30 day supply. Laundry area was toured. Chemicals, cleaning agents, and bleach were observed to be locked and made inaccessible to the residents at this time. First aid kit was observed to be present and contained all required components in the medication cabinet at this time.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MALONZO ELDERCARE, INC.	FACILITY NUMBER: 507005097
	VISIT DATE: 05/24/2021

NARRATIVE

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Linen closet was observed to be stocked and maintained with adequate supplies able to meet the needs of the residents at this time.
Garage area was toured.
An additional refrigerator/freezer was observed to be present storing food supplies for the facility staff.
A tour of the facility exterior grounds was conducted. Side gate, perimeter fence, and exterior exits were reviewed.

There were no deficiencies observed or cited during today's annual visit.

Exit Interview

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021

LIC809 (FAS) - (06/04)

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