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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801132
Report Date: 05/07/2025
Date Signed: 05/07/2025 05:31:03 PM

Document Has Been Signed on 05/07/2025 05:31 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:MADELAINE PLACE, INC.FACILITY NUMBER:
565801132
ADMINISTRATOR/
DIRECTOR:		ERLINDA GONZALESFACILITY TYPE:
740
ADDRESS:51 DOONE STREETTELEPHONE:
(805) 870-4117
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 5DATE:
05/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:ERLINDA GONZALES- Administrator TIME VISIT/
INSPECTION COMPLETED:
05:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 9: 45 a.m. Upon arrival, LPA Mosley was greeted by staff and called the Administrator to inform them of the visit. The Administrator arrived shortly after. The LPA met with Administrator Erlinda Gonzales and explained the reason for the visit. The LPA 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.

INTERVIEWS: From 9:55 a.m. – 10:16 a.m. One (1) staff and two (2) resident interviews were conducted during the inspection. Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interviews revealed that no concerns were noted or voiced at the time of the visit.

COMMON AREAS: At the time of the visit, furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. At 1:11 p.m., smoke detector(s) and carbon monoxide detectors were tested and operational at the time of the visit. The fire extinguishers were observed and fully charged on 12/17/2024. The LPA observed required postings throughout the common space. The last emergency disaster drill took place sometime in January 2025 and was not documented which poses/posed a potential health, safety or personal rights risk to persons in care. The Administrator was informed about the importance of emergency disaster drills and agreed to conduct a drill tomorrow and submit proof to CCLD.

Report Continued on LIC 809C PAGE 2...

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2025
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 05/07/2025 05:31 PM - It Cannot Be Edited


Created By: Erica Mosley On 05/07/2025 at 04:21 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MADELAINE PLACE, INC.
FACILITY NUMBER: 565801132

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(a)(2)(B)
Personal Accommodations and Services
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building.

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 in one (1) twin bed observed, in the non-permitted staff area in the garage which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2025
Plan of Correction
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Administrator agreed to not allow staff sleeping in this area and clear out all furniture (bed) and submit photos to LPA by 5/8/2024. Licensee/Administrator agreed to submit 24hr staffing schedule (LIC500).
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

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. The left side gate was blocked by a ladder, wheel barrel, generator, cart which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2025
Plan of Correction
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Administrator began relocating the items to the garage at the time of the visit and will have all items removed by end of the day. Administrator will send a photo proof to LPA that the passageway is free of obstruction by 05/08/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Erica Mosley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2025


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 05/07/2025 05:31 PM - It Cannot Be Edited


Created By: Erica Mosley On 05/07/2025 at 04:21 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MADELAINE PLACE, INC.
FACILITY NUMBER: 565801132

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 in seven (7) gallons of paint were accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/07/2025
Plan of Correction
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At the time of the visit the Administrator relocated the paint.
Type A
Section Cited
HSC
1569.695(a)(1)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (1) Evacuation procedures, including identification of an assembly point or points that shall be included in the facility sketch.

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 in not having an up to date accuate facility sketch with emergency exits listed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/07/2025
Plan of Correction
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At the time of the visit the Administrator updated and submited a facility sketch. Administrator agreed to submit a current and accurate official facility sketch to CCLD by 05/21/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Erica Mosley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 05/07/2025 05:31 PM - It Cannot Be Edited


Created By: Erica Mosley On 05/07/2025 at 04:21 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MADELAINE PLACE, INC.
FACILITY NUMBER: 565801132

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
(a) Prior to construction or alterations, all facilities shall obtain a building permit.

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 a room was observed in the garage and a bathroom in bedroom #6 without documentation of a building permit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/21/2025
Plan of Correction
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Administrator stated that will go to the City of Ventura to obtain a building permit if they are unable to obtain the permit they will remove the room / wall in the garage. They will update CCLD on what is advised regarding the bathroom in bedroom #6.
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, interview and record review, the licensee did not comply with the section cited above by not having documentation of drills and not have conducted a drill since January 2025 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2025
Plan of Correction
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Administrator agreed to conduct a drill tomorrow 05/08/2025 and will submit proof to CCLD by POC due 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Erica Mosley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2025


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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MADELAINE PLACE, INC.
FACILITY NUMBER: 565801132
VISIT DATE: 05/07/2025
NARRATIVE
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(PAGE 2) Report Continued from LIC 809...

Activities were observed in the common areas. An adequate supply of emergency food and water was observed. The facility has a working telephone on premises. Auditory alarms on all doors were functional at the time of the visit. Entry/exits in the home were free of obstruction. Inside temperature was maintained at a comfortable level.

KITCHEN: The LPA inspected the kitchen/food service area at 10:16 a.m. Knives and sharps were observed in a locked cabinet under the sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 110.4 degrees Fahrenheit at 10:21 a.m.

BEDROOMS: The facility is a single-story residential home with six (6) bedrooms of which six (6) are for resident use. Resident bedrooms are private, single occupancy. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

BATHROOMS: The facility has a total of four (4) bathrooms. Two (2) are private resident bathrooms and two (2) are shared, common bathrooms for resident use. Restrooms were clean and sanitary and in operating condition with grab bars and slip resistant surfaces. Hot water was measured in all resident bathrooms from 10:21 a.m. - 10:38 a.m. and measured between 109.8 – 110.8-degree Fahrenheit within the required range. The sinks had sufficient liquid soap, and paper towels. At approximately 10:31a.m. LPA observed that the private bathroom in bedroom # 6 was an alteration and does not have a permit which poses/posed a potential health, safety or personal rights risk to persons in care.

OUTDOOR SPACE/ GARAGE: The LPA observed the back yard which had four (4) portable outdoor umbrellas for shade along with patio furniture including tables and chairs for resident use. The LPA observed the right-side gate that self-latches with a clear passageway in case of an emergency. The left side gate was blocked by a ladder, wheel barrel, generator, cart, paint gallons posing an immediate health, safety or personal rights risk to persons in care. Administrator was informed of the dangers and advised to relocate all the items at the time of the visit. There were no bodies of water observed on the premises at the time of the visit. The garage is kept locked and inaccessible to residents.

Report Continued on LIC 809C PAGE 3...

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MADELAINE PLACE, INC.
FACILITY NUMBER: 565801132
VISIT DATE: 05/07/2025
NARRATIVE
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(PAGE 3) Report Continued from LIC 809C PAGE 2...

LPA observed an extra freezer with extra food that was checked for proper labels and expiration dates. Laundry units observed in the garage. Cleaning solutions, laundry detergent, toxins, chemicals, and hazardous items were inaccessible and locked away in the garage. At approx. 10:42 a.m. LPA observed an alteration to the garage of a wall that was added for a staff room that includes a bed, storage space and does not have a permit which poses/posed an immediate health, safety or personal rights risk to persons in care. The facility was cited last year for having a storage area that was converted to a staff sleeping area. The Administrator agreed to not allow staff to sleep in the area and clear out all furniture (bed).

RECORDS: Records review began at 10:54 a.m., five (5) resident records were reviewed for, but not limited to: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records in order. At 11:40 a.m. five (5) Personnel records including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

Infection Control / Emergency disaster planning: During today’s visit LPA Mosley reviewed the facility’s infection control practices and the facilities emergency disaster plan. The facilities policies and procedures as they pertain to infection control and emergency preparedness are adequate.

MEDICATIONS: Medications review began at approximately 2:03 p.m. Medications are centrally stored and locked in a closet adjacent to the entrance. Medications for four (4) residents were reviewed. Medications are labeled and checked for expiration dates. All medications were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records. No errors observed.

Documents obtained during the visit include: LIC 500 facility roster, LIC 9020A Resident roster, and current Liability Insurance. An updated facility sketch was requested.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. The Licensee was made aware that failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025
LIC809 (FAS) - (06/04)
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