565801132-5-20-2022-29-AS-MGCZ-CELNZ6-20220520105349

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801132
Report Date: 05/20/2022
Date Signed: 05/20/2022 10:54:54 AM

Document Has Been Signed on 05/20/2022 10:54 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MADELAINE PLACE, INC.		FACILITY NUMBER:	565801132
ADMINISTRATOR:	ERLINDA GONZALES		FACILITY TYPE:	740
ADDRESS:	51 DOONE STREET		TELEPHONE:	(805) 870-4117
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 4	DATE:	05/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Erlinda Gonzales		TIME COMPLETED:	11:00 AM

NARRATIVE

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Licensing Program Analyst (LPA) Martha Guzman Chavez arrived at the facility unannounced to conduct a required annual visit at 9:30 a.m. The last annual conducted at this facility was on 4-24-2019. This annual has a specific emphasis on infection control practices and procedures. The LPA was greeted and scanned at the door by Staff Romel. The Administrator, Erlinda arrived shortly afterwards and was explained the reason for the visit. Entrance interview.

At 9:45 a.m., the LPA began the physical plant tour of the common areas, kitchen area, resident bedrooms, staff room, bathrooms, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The LPA observed knives and sharps in the cabinet under the sink locked and inaccessible to residents.

BEDROOMS: The LPA observed the resident rooms, which were furnished appropriately with clean linens, furnishings, and sufficient lighting.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms are sufficiently stocked with hand liquid soap and paper towels. The appropriate hand-washing signs were observed in the restrooms. Bathrooms were measure for hot water, the first bathroom is private inside bedroom #1 and it measured at 105.8 degrees Fahrenheit and the second bathroom measured at 113.4 degrees Fahrenheit.

…Continued on LIC 809C…

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MADELAINE PLACE, INC.	FACILITY NUMBER: 565801132
	VISIT DATE: 05/20/2022

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...Continued from LIC 809...

GARAGE AND GROUNDS: The garage is locked and attached to the house. Cleaning supplies and chemicals are stored and inaccessible to residents. There is one (1) additional freezer in the garage with perishable items in good condition. There is a covered patio area with patio furniture including several tables and chairs for resident use. Facility has one (1) fence gate that self-latches with clear passageways for emergency exit use. The LPA observed two (2) gallons of paint on the side of the house. The Administrator immediately removed the paint and placed in a locked cabinet in the garage. No large bodies of water accessible to residents.

COMMON SPACES: The living and dining areas are clean and properly furnished with seating, a table, and television for resident use. Medications are in a locked closet adjacent to the living room area.

During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, and symptoms of COVID-19. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) in the garage and the facility is able to obtain additional supplies as needed. Staff were observed wearing face coverings. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

The LPA and Administrator discussed staff vaccination requirements. All staff are fully vaccinated. No identified staffing concerns. The facility is in compliance regarding the requirements for indoor and outdoor visitation. The facility’s policies and procedures as it pertains to infection control are adequate.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted. Appeal Rights Discussed. A copy of the report was provided via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/20/2022 10:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MADELAINE PLACE, INC.	FACILITY NUMBER: 565801132
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation during physical plant tour, the Licensee failed to ensure that all toxins such as paint are kept locked and inaccessible to residents, which poses an immediate health and safety risk to the resident in care.
	POC Due Date: 05/20/2022
	Plan of Correction
1 2 3 4	The Administrator immediately removed the paint gallons and placed them in a locked cabinet in the garage. Cleared during visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC809 (FAS) - (06/04)

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