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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004711
Report Date: 10/27/2021
Date Signed: 10/27/2021 03:31:20 PM

Document Has Been Signed on 10/27/2021 03:31 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MADISON GUEST HOMEFACILITY NUMBER:
306004711
ADMINISTRATOR:CELSO C. LAPINIDFACILITY TYPE:
740
ADDRESS:219 E. MADISON AVENUETELEPHONE:
(714) 646-9364
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 6DATE:
10/27/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Arlyne and Dennis CornesoTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analysts Michelle Reed and Beverly Thompson-Gracia conducted an unannounced visit to the facility for the purpose of conducting a Case Management visit. Upon arrival, LPA met with Staff Arlyne and Dennis Corneso. Administrator Celso Lapinid was spoken to via telephone.

On 9/4/20 the Licensee requested an exception for R1 to have a feeding tube. R1 was not receiving hospice services but was receiving home health. On 7/20/21 the Licensee requested to allow R2 to have a feeding tube. R2 was also not receiving hospice services. The Department denied both exceptions on 7/29/21 and Mr. Lapinid was told that residents would need to be receiving hospice services or relocated.

On today's date, R1 and R2 were still present at the facility with their feeding tubes. R1 was not receiving hospice services. R2 was placed on hospice services on 8/16/21. When R2's file was reviewed there was no care plan in the file.

See LIC809D for cited deficiencies.

An exit interview was conducted with Staff Dennis Corneso and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
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
Document Has Been Signed on 10/27/2021 03:31 PM - It Cannot Be Edited


Created By: Michelle Reed On 10/27/2021 at 02:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MADISON GUEST HOME
FACILITY NUMBER: 306004711

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/28/2021
Section Cited
CCR
87615(a)(2)

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Prohibited Health Conditions-Persons who require Gastrostomy tubes shall not be admitted or retained in a residential care facility for the elderly.

This requirement was not met as evidenced by:
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Administrator stated that R1 will be placed on hospice services or will be relocated. R2 is receiving hospice services and will not need to be relocated. Proof of correction will be provided by 10/29/21.
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On 7/29/21 the Department denied exceptions for R1 and R2 to have Gastrostomy tubes. The Licensee failed to relocate R1 and R2 after the Department's denial. Both residents were present at the facility on today's date.
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Type B
10/29/2021
Section Cited
CCR87633(b)

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Hospice Care of Terminally Ill Residents-A current and complete hospice care plan shall be maintained in the facility for each hospice resident.

Licensee failed to have a current and complete hospice care plan for R2.
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Licensee agrees to update R2's hospice care plan as well as all hospice care plans for resident's in the facility. Certification shall be provided of completion. R2's care plan was faxed at the time of visit to LPAs.

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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:Sheila Santos
LICENSING EVALUATOR NAME:Michelle Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2021


LIC809 (FAS) - (06/04)
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