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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004711
Report Date: 05/28/2025
Date Signed: 05/28/2025 04:09:19 PM

Document Has Been Signed on 05/28/2025 04:09 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/
DIRECTOR:		CELSO C. LAPINIDFACILITY TYPE:
740
ADDRESS:219 E. MADISON AVENUETELEPHONE:
(714) 646-9364
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 6DATE:
05/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Arlyne CornejoTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by staff Arlyne Cornejo and explained the purpose of the inspection.

During the inspection, LPA and Staff Cornejo conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:

This is a one-story home with six resident bedrooms, one staff bedroom, three bathrooms, and attached two-car garage. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. The backyard has a shaded sitting area. LPA observed residents watching television in the living room and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 138.3 – 152.6 degrees Fahrenheit; a Deficiency was cited on today’s date.

LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents. Medication cabinet was observed to be locked; however, medication is being pre-poured into a plastic weekly medication organizer for each resident; a Deficiency was cited on this date. Upon review of Resident 1's (R1's) medication records, there was no authorization from their physician for one of their prescribed medications and staff was unable to provide LPA with a copy of authorization; a Deficiency was cited on today's date. Medication requiring refrigeration was also observed to be to accessible to all facility residents in the kitchen fridge; a Deficiency was cited on today's date. (Cont. LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Claudia Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/28/2025 04:09 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 05/28/2025 at 02:47 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: 05/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(5)(A)
Incidental Medical and Dental Care Services
(5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following: (A) Medications usually prescribed for self-administration which have been authorized by the person's physician.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as there is no authorization from a resident's physician for one of their prescribed medications, which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date: 05/29/2025
Plan of Correction
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Staff Cornejo stated an authorization for resident's prescribed medication will be obtained and a copy provided to LPA via email by POC date.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as medication requiring refrigeration was observed to be accessible to all facility residents in the kitchen fridge, which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date: 05/29/2025
Plan of Correction
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Staff Cornejo stated a medication lock box will be obtained and used to centrally store medication requiring refrigeration and proof provided to LPA via email by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:
Claudia Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2025


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 05/28/2025 04:09 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 05/28/2025 at 02:47 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: 05/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as water temperature tested between 138.3 and 152.6 degrees Fahrenheit, which poses a potential safety risk to persons in care.
POC Due Date: 06/27/2025
Plan of Correction
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Staff Cornejo stated water temperature would be tested and a water temperature log maintained in order to ensure water temperature consists of 105 to 120 degrees Fahrenheit and proof provided to LPA via email by POC date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and staff interview, the licensee did not comply with the section cited above as staff files reviewed did not include 20 hours of annual training conducted, which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 06/27/2025
Plan of Correction
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Staff Cornejo stated 20 hours of annual staff training will be completed and proof provided to LPA via email by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:
Claudia Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/28/2025 04:09 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 05/28/2025 at 02:47 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: 05/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and staff interview, the licensee did not comply with the section cited above as medication for residents is being pre-poured into a plastic weekly medication organizer three days in advance, which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 06/27/2025
Plan of Correction
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Staff Cornejo stated medication will no longer be transferred between the original prescription container and into the weekly container and staff training will be conducted on proper medication storage, and a copy of staff training will be provided to LPA via email by POC date.
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as three of three resident files reviewed did not include a pre-admission appraisal, which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 06/27/2025
Plan of Correction
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Staff Cornejo stated resident files will be updated to include a pre-admission appraisal and a copy provided to LPA via email by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:
Claudia Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 05/28/2025 04:09 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 05/28/2025 at 02:47 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: 05/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as two of three resident files reviewed did not include an updated pre-admission appraisal, which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 06/27/2025
Plan of Correction
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Staff Cornejo stated resident files will be updated to include updated pre-admission appraisal and a copy provided to LPA via email by POC date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and staff interview, the licensee did not comply with the section cited above as emergency drills are currently not being conducted, which poses a potential safety risk to persons in care.
POC Due Date: 06/27/2025
Plan of Correction
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Staff Cornejo stated emergency drills will be conducted and the type of emergency covered in the drill will vary from quarter to quarter and proof will be provided to LPA via email by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:
Claudia Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 306004711
VISIT DATE: 05/28/2025
NARRATIVE
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LPA reviewed three resident files and observed three of three files did not include a pre-admission appraisal. One of three resident files did not include an updated appraisal dated or signed in the last twelve months; a Deficiency was cited on today’s date. LPA reviewed two staff files and observed two of two staff files did not contain any documentation for staff training conducted in the past year and staff was unable to provide LPA with a copy of staff training conducted; a Deficiency was cited on today’s date. LPA interviewed three residents and two staff.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Claudia Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC809 (FAS) - (06/04)
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