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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005097
Report Date: 01/27/2022
Date Signed: 02/08/2022 02:24:04 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 LANETELEPHONE:
(949) 378-1285
CITY:MODESTOSTATE: CAZIP CODE:
95358
CAPACITY:5CENSUS: 4DATE:
01/27/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Cleofe MalonzoTIME COMPLETED:
04:00 PM
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Unannounced annual visit made out to this facility on 01/27/2022 by LPA Charlie Yang and was met by the facility designated Administrator Cleofe Malonzo. Brief interview conducted with the facility designated Administrator.
It was learned that this facility does have (1) resident under the care of hospice at this time. This facility is licensed to accept and retain up to (2) residents under hospice care. There weren't any residents under the care of home health at this time.
Tour of this facility was conducted.
Kitchen area was toured. Cabinets and drawers were reviewed. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time stored in the pantry area.
Garage area was toured and observed to be utilized as main storage unit at this time with items for facility use and other items intended for resident use.
Resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Resident restrooms were toured. Grab bars and non skid mats were observed to be present and able to meet the needs of the residents at this time.
Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
Linen closet, located in hallway, was reviewed and observed to contain a sufficient supply of blankets, bed coverings, and towels to meet the needs of the residents at this time.
Living room, dining room and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.
Medication cabinet, located in the kitchen area, was observed to be locked and made inaccessible to the residents at this time.
First aid kit, located in the medication cabinet, was observed to contain all of the required components at this time.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 01/27/2022
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Fire extinguisher, located in the kitchen area, was observed to have been annually purchased on 03/21/2021 with a proof of purchase attached. Brief conversation was held with the facility designated Administrator to inform her that it was soon due for an annual inspection or purchase of another unit.
Exterior grounds of this facility were reviewed.
The perimeter fence, side gates, and all exits were reviewed and observed to be in compliance at this time.

The following forms and documents were requested to be updated and submitted into CCL:
  1. LIC 308
  3. LIC 400
  5. LIC 500
  7. LIC 610

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

Exit Interview
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2