Maddie's Green Haven Facility

Type of visit: Prelicensing

Licensing Program Analyst(LPA) Christine Yee conducted a subsequent announced Prelicensing and Component III visit to ensure that the deficiencies observed on the initial Prelicensing visit conducted on 10/30/2025 were corrected and to complete Component III. LPA Yee met with Junaida Shakhvaladyan, Applicant. Per tour of the home on today's visit, the following corrections were made: the queen size bed in bedroom #4 and full size bed in bedroom #2 were replaced with 2 beds in each room. another chair was placed in bedroom #2, #3 and 2 chairs were place in bedroom #4 a shared dresser was placed in bedroom #2, #3 and #4 another night stand and lamp was placed in bedroom #2 bed rails were removed from the hospital beds in bedroom #3 sufficient blankets and sets of towels were purchased in quantities to allow for changing the hardwired combination smoke/carbon monoxide detectors were placed in all the resident rooms, staff rooms, hallways, living room and dining room. All were tested individually and were operational. plenty of non-perishable foods for a minimum of 7 days were observed 13 five gallon bottles of water were observed hygiene products were observed in a locked cabinet located inside the only common bathroom. the shoe rack by the front door was relocated The fire safety plan was reviewed. continued on LIC809-C Page 2. The Applicant provided a copy of the Emergency Disaster Preparedness Plan for review. A copy was also emailed to LPA. Chairs were added in the living room to allow seating for 6 residents the heater wires for the wall heater mounted in bedroom #4 were removed and does not generate heat and is used decoratively. The facility telephone - (747) 264-0754 was tested and was operational a first aid manual was observed the backyard was cleaned and all stored items noted on the initial report had been removed. COMPONENT III was conducted with the Applicant on today's visit. The Applicant was reminded to do the following once the licensing process has been completed: purchase general liability insurance with limits of $1 million per occurrence and $3 million total annual aggregate create files for all staff, all residents and volunteers if applicable ensure that all staff and any persons who are required to have a criminal record clearance have obtained the clearance and have requested a criminal record transfer prior to their initial presence at the facility notify the Department of the acceptance of the first resident within 5 days of acceptance. purchase perishable foods for a minimum of 2 days prior to the acceptance of the first resident As of this visit, there is no obvious corrections identified to hold up the clearance of the home. Exit interview was conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 15, 2026

Type of visit: Prelicensing

Licensing Program Analyst(LPA) Christine Yee conducted an announced Prelicensing and Component III visit to ensure that the home meets Title 22 requirements. The CARE Inspection Tool was used to conduct the visit. LPA Yee met with Junaida Shakhvaladyan, Applicant. The home is a single storey family home consisting of a living room, dining room, kitchen, 4 bedrooms of which one is designated for live-in staff, 3 full bathrooms and a attached garage. The facility is fire cleared for 5 NON-AMBULATORY and 1 BEDRIDDEN residents. On today's visit, LPA Yee reviewed all 12 domains of the CARE Inspection Tool, reviewed the Emergency and Disaster Plan, Residential Infection Control Plan and toured the entire physical plant, inside and outside. The following were observed: The living room is furnished with a sofa, 2 armchairs, 2 coffee tables, a wall mounted television and a television stand. Additional seating is needed. The fire place is made inaccessible by a fire screen. The dining room is furnished with a long table and six chairs, a buffet table, 2 plant stands with potted plants and the centrally stored medication cart. The kitchen is equipped with a stove, dishwasher, refrigerator, microwave, air fryer and a toaster oven. There are sufficient dinner plates, salad bowls, glasses, cups, soup bowls, knives, forks and spoons. Pots and fry pans were observed. There were no perishable foods purchased. Non-perishable foods were observed in the attached garage but were not in quantities to last for 7 days. Knives are stored in a continued on LIC809-C Page 2. locked cabinet and dish soap and cleaning supplies are stored in a locked cabinet under the kitchensink. Laundry detergent and additional cleaning solutions are stored in a locked cabinet in the garage. Also located in the kitchen is a round table with 4 dining chairs and a fire extinguisher purchased on 6/25/25. The facility has a second fire extinguisher that is not currently mounted. Bedroom #1, located by the front door is designated for staff use. It is furnished with a full size bed, a night stand a lamp, a built in closet, a desk and a coffee table. Bedroom #2 is furnished with a full size bed, a night stand, a chair, 1 night stand, a lamp, a built in closet and a mounted television. The required linens were observed except for a blanket. Located inside the bedroom is a bathroom equipped with a walk-in shower, a toilet and a single sink vanity. Grab bars were observed in the shower and on the wall directly by the shower. A grab bar is needed by the toilet. A slip resistant mat was observed The water temperature was taken and it read 114.2 degrees Fahrenheit. Blinds were observed on the 2 windows. Bedroom #3 is furnished with 2 hospital beds with half bed rails, 1 chair, 2 lamps, a built in closet and a sliding glass door. Located outside is a ramp. A auditory device was mounted on the door. Bed linens were observed but there was no blanket. The common bathroom is equipped with a bath tub/shower, a toilet, single sink vanity and storage cabinets. Grab bars and a slip resistant mat were observed. Water temperature was tested and read 112.6 degrees Fahrenheit. Bedroom #4 is furnished with a queen sized bed, 2 night stands, 2 lamps, connected armchairs, a walk in closet and a wall heater. Located inside is a bathroom equipped with a shower stall, a toilet, a single sink vanity and a large jacuzzi tub.. Grab bars and a slip resistant mat were observed in the shower and by the toilet. The water temperature was tested and read 106.5 degrees Fahrenheit. The linen closet was observed with 7 sets of towels, 6 sets of twin sheets. The first aid kit was observed with the appropriate gauze, salves, bandages, tweezers, scissors and thermometer. No first aid manual was observed. All the windows had blinds for privacy and the screens were observed to be in good condition. continued on LIC809-C Page 3 The smoke detectors were tested individually and were operational except for the smoke detector located by the front door. The smoke detector was missing. The attached garage houses the washer and dryer and is primarily used for storage. The 2 non-operational refrigerators need to be discarded. The backyard has a covered patio furnished with plenty of chairs and a table. Also located in the back is a free standing gazebo equipped with benches and barbecue grills and directly adjacent to the gazebo are additional chairs. 2 storage sheds were observed. Ladders, hoyer lift, swing set, wood, cleaning buckets, mops were stored in the back and along the side of the home. Otherwise the back yard was observed to be clean The front yard was also observed to be clean but the water hose needs to be rolled up. The following corrections need to be addressed prior to licensure: the queen size bed in bedroom #4 and full size bed in bedroom #2 needs to be replaced with 4 individual beds. A chairs needs to be placed in bedroom #2, #3 and 2 chairs in bedroom #4 a dresser is needed in bedroom #2, #3 and #4 a night stand in bedroom #2 remove bed rails from the 2 hospital beds in bedroom #3 purchase blankets and sets of towels in quantities to allow for changing weekly or as needed. purchase a carbon monoxide detector, if smoke detectors are not combination carbon/smoke detectors. replace the smoke detector by the front door. purchase additional non-perishable foods for a minimum of 7 days purchase hygiene products. remove the shoe rack located by the front door. complete a fire safety plan review and revise the Emergency Disaster Preparedness Plan continued on LIC809-C Page 4. add additional seating in the living room for 6 residents secure and make the wall heater inaccessible to the residents purchase a telephone for the facility and ensure the telephone is operational purchase a first aid manual that is approved by the American Red Cross discard or store the ladders, buckets, mops, exercise equipment stored out in the back and along the side of the home and roll up the garden hose in the front Applicant to notify LPA Yee once the corrections have been completed, but longer than 11/6/25 to schedule a second visit to clear the home. COMPONENT III was not conducted on today's and will be scheduled on the return visit. Exit interview was conducted.the state’s words, verbatim · CDSS document, Oct 30, 2025

Type of visit: Office

COMP II by CAB successfully completed Method: Phone Call at CAB Applicant/administrator participated in COMP II at CAB telephone call with analyst at CAB. Identification of the applicant and administrator was verified by presenting photo ID via phone. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of propertythe state’s words, verbatim · CDSS document, Sep 16, 2025