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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004711
Report Date: 10/23/2025
Date Signed: 10/23/2025 02:42:41 PM

Document Has Been Signed on 10/23/2025 02:42 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:
10/23/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Arlyne CornejoTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced Plan of Correction (POC) inspection for the purpose of following up on deficiencies cited during required annual inspection. LPA was greeted and granted entry by Staff Arlyne Cornejo and purpose of the visit was discussed.

Deficiency 87465(a)(5)(A) was cited due to there being no authorization from Resident’s 1 (R1’s) physician for one of their prescribed medications. During today’s visit, LPA observed there is still no authorization from R1’s physician for one their prescribed medications. Per Staff, medication has been discontinued however was unable to provide a discontinued order from R1’s physician and the medication remains with R1’s centrally stored medication.

Deficiency 87465(h)(2) was cited due to medication requiring refrigeration being observed to be accessible to all facility residents in the kitchen fridge. During today’s visit, LPA observed there is a separate mini fridge with a lock in which medication requiring refrigeration is centrally stored.

Deficiency 87303(e)(2) was cited due to water temperature testing between 138.3- and 152.6-degrees Fahrenheit. During today’s visit, water temperature tested at 131.0 degrees Fahrenheit.

Deficiency 1569.625(b)(2) was cited due to staff files not containing 20 hours of annual training conducted. During today’s visit, LPA conducted file review for two of two staff files and observed files did not contain 20 hours of annual training. Per Staff, they have not completed required annual staff training.

Deficiency 87465(h)(5) was cited due to medication for residents being pre-poured into a plastic weekly medication organizer three days in advance. During today’s visit, LPA observed medication for residents is no longer being pre-poured. (Cont. LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Claudia Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2025
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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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: 10/23/2025
NARRATIVE
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Deficiency 87506(b)(15) was cited due to three of three resident files reviewed not including a pre-admission appraisal. During today’s visit, LPA conducted file review for three of three resident files and observed a pre-admission appraisal remains to be completed for three of three residents.

Deficiency 87463(a) was cited due to two of three resident files reviewed not including an updated pre-admission appraisal. During today’s visit, conducted file review of resident files and observed pre-admission appraisals to be updated.

Deficiency 1569.695(c) was cited due to emergency drills not being conducted. During today’s visit, Staff stated emergency drills are still not being conducted.

Three of eight POCs have been met and three deficiencies previously cited for will be cleared.

Based on today’s observations 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: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 10/23/2025 02:42 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 10/23/2025 at 02:06 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: 10/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2025
Section Cited
CCR
87465(a)(5)(A)

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(5)... 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:
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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.
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Based on observation and staff interview, the licensee did not comply with the section cited above as there is no authorization from R1’s physician for one their prescribed medications and the medication remains with R1’s centrally stored medication.
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Type B
11/21/2025
Section Cited
CCR87303(e)(2)

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(2)... Hot water temperature controls shall be maintained to automatically regulate the temperature... to attain a temperature of not less than 105 degree F... and not more than 120 degree F (49 degrees C).

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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.
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Based on observation, the licensee did not comply with the section cited above as water temperature tested at 131.0 degrees Fahrenheit which poses a potential safety risk to persons in care.
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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.
Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:
Claudia Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/23/2025 02:42 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 10/23/2025 at 02:14 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: 10/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2025
Section Cited
HSC
1569.625(b)(2)

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(2)... training requirements shall... include... 20 hours annually, eight hours of which shall be dementia care training... and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care...
This requirement is not met as evidenced by:
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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.
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Based on observation and staff interview, the licensee did not comply with the section cited above as staff files did not include 20 hours of annual training conducted, which poses a potential health, safety and personal rights risk to persons in care.
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Type B
11/21/2025
Section Cited
CCR87506(b)(15)

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(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal...

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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.
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Based on observation and record review, the licensee did not comply with the section cited above as 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.
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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.
Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:
Claudia Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/23/2025 02:42 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 10/23/2025 at 02:24 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: 10/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2025
Section Cited
HSC
1569.695(c)

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(c) A facility shall conduct a drill at least quarterly for each shift... 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.

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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.
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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.
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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.
Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:
Claudia Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2025


LIC809 (FAS) - (06/04)
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