565801132-5-23-2023-29-AS-ECAS-CS4UYN-20230523160009

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801132
Report Date: 05/23/2023
Date Signed: 05/23/2023 04:00:27 PM

Document Has Been Signed on 05/23/2023 04:00 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
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: 5	DATE:	05/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Erlinda Gonzales		TIME COMPLETED:	04:15 PM

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Licensing Program Analysts (LPA’s) Elsie Campos and Sandra Urena arrived at the facility unannounced to conduct a required annual visit at 11:20 a.m. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Erlinda Gonzales arrived shortly thereafter.

The LPA’s and the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

BEDROOMS: The LPAs began the inspection in bedroom area at 11:35 a.m. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are five designated client rooms and one staff room.

RESTROOMS: The three client restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured in the hallway restroom at 106.2 degrees Fahrenheit.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is blocked by a tv console and inaccessible. The facility maintained a comfortable temperature of 76 degrees. Smoke detector(s) and carbon monoxide detector were tested at 12:12 p.m. and operational at the time of the visit. The one (1) fire extinguisher was fully charged and was last serviced Nov 29, 2022. The LPAs observed required postings throughout the common space. The Administrator was advised to post the Community Care Licensing Personal Rights form on the bulletin board.

KITCHEN: The LPAs conducted an inspection of the kitchen at 11:50 a.m. Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The Administrator was advised to monitor perishable items for expiration. ***Continued on LIC 809-C***

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

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: 05/23/2023

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OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single latched. No bodies of water noted. The garage is where the washer and dryer are held, including additional freezer with perishable food items. Cleaning supplies and disinfectants are kept in locked in the garage.

RECORDS: Residents’ records review began at 1:00 p.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order.

Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 2:00 p.m.; medications are centrally stored and locked in a closet at the entrance of the facility. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPAs discussed the new PIN changes regarding infection control.

The LPAs obtained the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster
- Staff schedule

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

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