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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202805
Report Date: 09/03/2021
Date Signed: 09/07/2021 07:43:47 AM

Document Has Been Signed on 09/07/2021 07:43 AM - 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SWANER GUEST HOME IIFACILITY NUMBER:
275202805
ADMINISTRATOR:MAGSAMBOL, MATTHEWFACILITY TYPE:
740
ADDRESS:978 ESTRADA COURTTELEPHONE:
(831) 449-9379
CITY:SALINASSTATE: CAZIP CODE:
93907
CAPACITY: 6CENSUS: 6DATE:
09/03/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:13 PM
MET WITH:Matthew MagsambolTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Ryker Heberle conducted an unannounced pre-licensing inspection today. LPA met with Administrator (ADM) Matthew Magsambol.

At around 12:13pm, LPA toured the facility inside and out. Including kitchen, dining room, 2 living rooms, 3 resident bedrooms, and 2 staff bedrooms. A screening station is observed by the entry door for anyone coming in the facility.

The facility is equipped with connected smoke detectors. The smoke detector located in the living room by the entry was tested and observed working. All fire/carbon monoxide detectors observed to be connected. 2 fire extinguishers were observed in the kitchen and living room respectively which had tags indicating service in December 2020. The kitchen, dining, and living room were observed in good repair. Resident and personnel files observed to contain all necessary documentation.

Resident bedrooms were observed in good repair, furnished, with clean linens and adequate lighting. Bathrooms were observed clean and equipped with grab bars and non-skid mats. The water temperature in bathroom #2 was measured at 114 degrees F. Centrally stored medication cabinet, and a cabinet with non-perishable and emergency food supplies. A complete first aid kit was inspected. The backyard was inspected. All outdoor and indoor passageways were observed clear and free of obstruction. No bodies of water observed.

Component III orientation was conducted. No deficiencies cited. The physical plant is approved pending the completion of vendorization with San Andreas Regional Center and review of the facility application by Centralized Application Bureau (CAB). Exit interview conducted with and copy of report provided to Matthew Magsambol.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2021
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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