507005097-3-7-2023-27-AS-CYAG-CPPPUA-20230307103713

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507005097
Report Date: 03/01/2023
Date Signed: 03/07/2023 10:37:18 AM

Document Has Been Signed on 03/07/2023 10:37 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
SACRAMENTO AC/SC, 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:	03/01/2023
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	11:00 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 03/01/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Cleofe Malonzo who was briefly interviewed. It was learned that this facility accepted and retained elderly residents, age range 60 years of age and older, at this time. This facility is also vendorized through Valley Mountain Regional Center to accept and retain Level 4F, and higher, residents at this time. Current census was 4 residents. Tour of this facility was conducted. Dining area, living area, and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time. A tour of the front resident bedroom was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. A tour of the resident restroom was conducted. Hot water temperature was taken and measured to make sure that it was within the allowed range of 105-120 degrees. Fire extinguisher, located hanging in the kitchen area, was observed to have been annually purchased on 03/17/2022 from the local Costco store and in compliance at this time. Kitchen area was toured. Cabinets and drawers were reviewed. Food supply was reviewed to make sure that there was an adequate supply of 2-day perishable and 7-day nonperishable quantities at all times. Medication cart, located in the kitchen area, was observed to be locked and made inaccessible to the residents at this time. A brief review of the medications and dispensing policies and procedures were discussed with the facility designated Administrator at this time. First aid kit, located in a medication cart, was observed to be present and contained all of the required components at this time. A tour of the resident bedrooms was conducted. Resident bedroom furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. A tour of the resident restrooms was conducted.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023

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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MALONZO ELDERCARE, INC.	FACILITY NUMBER: 507005097
	VISIT DATE: 03/01/2023

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
26
27
28
29
30
31
32

Linen closet, located in facility hallway leading to the resident bedrooms, was observed to be supplied with a sufficient supply of blankets, towels, and bedspreads at this time.
Laundry area was toured. It was learned that there were other cabinets used in the garage area that were locked to make cleaning and laundry supplies inaccessible to the residents at this time.
Garage area was toured.
Exterior grounds of this facility was reviewed. A review of the facility perimeter fence, side gates, and exits was conducted.

The following forms and documents were requested to be updated and submitted into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

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

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2