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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247203432
Report Date: 12/12/2025
Date Signed: 12/30/2025 10:58:39 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/10/2025 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20250910190809
FACILITY NAME:GUARDIAN ANGEL HOME CARE IIFACILITY NUMBER:
247203432
ADMINISTRATOR:SILVEIRA, LIDIAFACILITY TYPE:
740
ADDRESS:194 CLIPPER COURTTELEPHONE:
(209) 605-5239
CITY:ATWATERSTATE: CAZIP CODE:
95301
CAPACITY:6CENSUS: 5DATE:
12/12/2025
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Facility staff, Terry LaceyTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
Staff neglect resulted in a resident to be hospitalized
Staff did not provide adequate care and supervision
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to open a complaint investigation. LPA met with facility House Manager, Terry Lacey and explained the purpose of today's visit.

Regarding the allegation Staff neglect resulted in a resident to be hospitalized. Facility staff was in the facility bathroom with Resident 1 assisting with activities of daily living when they fell. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.




Continued...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/10/2025 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20250910190809

FACILITY NAME:GUARDIAN ANGEL HOME CARE IIFACILITY NUMBER:
247203432
ADMINISTRATOR:SILVEIRA, LIDIAFACILITY TYPE:
740
ADDRESS:194 CLIPPER COURTTELEPHONE:
(209) 605-5239
CITY:ATWATERSTATE: CAZIP CODE:
95301
CAPACITY:6CENSUS: 5DATE:
12/12/2025
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Facility staff, Terry LaceyTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not properly position a resident while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to open a complaint investigation. LPA met with facility House spoke over the phone with facility staff, Terry Lacey and explained the purpose of today's visit.


Regarding the allegation Staff did not properly position a resident while in care. Witness observed Resident 1 not properly poistioned onto their bed. The facility staff does not have training on how to correctly position Resident 1 in their bed. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

The following deficncies are being cited per title 22 regulations, A copy of this report along with appeals rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 24-AS-20250910190809
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: GUARDIAN ANGEL HOME CARE II
FACILITY NUMBER: 247203432
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2025
Section Cited
CCR
87464(f)(1)
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87464 Basic Services
(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports.
The following requirement has not been met as evidenced by:
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Licensee will conduct training on correct positioning and submit to LPA by POC date of 12/13/2025.
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Resident 1 was observed not properly positioned in their bed, which poses an immediate, health, safety, or personal rights risk to residents in care.
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7
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5
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7
1
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7
1
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7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20250910190809
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: GUARDIAN ANGEL HOME CARE II
FACILITY NUMBER: 247203432
VISIT DATE: 12/12/2025
NARRATIVE
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Regarding the allegation Staff did not provide adequate care and supervision. The facility staff was present and supervising resident 1 when the fall occurred. The facility staff was providing care to Resident 1 when the fall took place. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.


Exit interview conducted with facility House Manager Terry Lacey , and copy of report provided
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4