Inspection Report Summary for Madonna Gardens Assisted Living & Memory Care

The California Department of Social Services Community Care Licensing (CCLD) conducted several unannounced inspections of facility 275202569, known as **Carefield at Madonna Gardens** (also referred to as **Madonna Gardens**). Over the period from July 2021 through June 2024, the visits revealed a mixture of strengths and persistent compliance challenges. Early inspections in July 2021 and a subsequent annual inspection in May 2023 found the facility to be in good physical condition, with proper infection‑control measures, functioning safety equipment, and a clean, well‑maintained environment. No deficiencies were cited during those visits.

In contrast, later visits highlighted recurring issues. The November 2021 tele‑visit noted a COVID‑19 outbreak with eleven positive residents and zero positive staff. The LPA and nurse recommended enhanced PPE practices, better trash handling, and improved donning/doing stations, but no deficiencies were formally cited. In May 2022, a case‑management visit identified a serious supervision lapse when Resident 1 went AWOL during an activity; the incident demonstrated that the facility failed to provide adequate care and supervision, leading to a cited deficiency under Title 22, Division 6. A month later, in May 2023, the LPA observed that all outer bedroom doors in the Memory Care area were locked, preventing rapid access for staff and emergency personnel. This situation was cited as a deficiency for not meeting fire‑clearance and emergency‑response requirements for residents with dementia.

The June 2024 visit was recorded but the report content is incomplete in the supplied text; it confirms that the facility continued to be under inspection. Overall, the pattern that emerges is a facility that maintains solid physical and infection‑control standards but repeatedly encounters deficiencies related to resident supervision, emergency preparedness, and appropriate use of security measures. Continued oversight and corrective action will be necessary to address these safety and compliance gaps.