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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202805
Report Date: 02/02/2023
Date Signed: 03/21/2023 03:25:47 PM

Document Has Been Signed on 03/21/2023 03:25 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
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: 5DATE:
02/02/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee / Administrator Mathew MagsambolTIME COMPLETED:
11:15 PM
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An informal conference was conducted today 02/02/2023 in the Fresno Regional Office. The purpose of this informal conference meeting is to discuss the facilities multiple Type A citing’s during the recent Annual Inspection. Present in the meeting is Licensing Program Manager Brenda Chan, Licensing Program Analyst Sarah Hurt, Licensee/Administrator Mathew Magsambol, and Licensee/ Administrator Rosario Magsambol.
Issues discussed during the meeting were:
· Food service
· Chemicals accessible to residents
· Facility is not clean and in good repair
· Facility water temperature is too hot
· Medications not being logged correctly on Medication Administration Record & Centrally Stored Logs
· Incidental Medical and Dental (residents not having medications for several days)
· Facility staff does not have required CPR/First Aid Training
· Qualifications of Administrator Mathew Magsambol

The facility has stated they will do the following to achieve continued and substantial compliance:
· Conduct frequent training with facility staff related to daily facility operating tasks
Conduct Food Service Requirements training with facility staff
· Frequently check facilities water temperature
· Keep chemicals in garage and kitchen locked away and inaccessible to residents, along with conducting staff training on proper chemical storage.
· Provide updated floor plan to include one storage room (store clutter)
· Ensure the facility, and all resident bedrooms are clean and not full of clutter.
Fix broken dressers in resident bedrooms
Ensure the facility room temperature is within required regulation temperature. (minimum of 68 degrees)
Utilize online Resources provided to ensure facility remains in compliance
Submit Plan of Corrections by due dates, and if unable request an extension.

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SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: SWANER GUEST HOME II
FACILITY NUMBER: 275202805
VISIT DATE: 02/02/2023
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Continued from 809..

Licensing Program Manger Brenda Chan offered several online resources including Technical Support Program (TSP), Self-Assessment Guide, Medication Guide, and HCO Resources offered by Department of Social Services to assist Licensee’s Rosario Magsambol, and Mathew Magsambol with coming into compliance

Licensee Mathew Magsambol agreed to submit an updated LIC 308, LIC 500, and LIC 309 to Licensing by 02/09/2023. Licensee Mathew Magsambol agreed to research the TSP program and consider enrolling. Licensee Mathew Magsambol agreed to submit a written plan to Licensing on how they will oversee the daily operations of the facility, monitor the quality and amount of staff present at the facility, and improve daily operations of the facility by 02/09/2023.

Exit interview conducted and a copy of this report provided to Licensee/ Administrator Mathew Magsambol

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023
LIC809 (FAS) - (06/04)
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