275202805-12-16-2024-24-AS-BCHN-DCFUXH-20241230145820

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 275202805
Report Date: 10/03/2024
Date Signed: 12/16/2024 06:17:14 PM

Substantiated

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
10/01/2024 and conducted by Evaluator Sarah Hurt

COMPLAINT CONTROL NUMBER: 24-AS-20241001165356

FACILITY NAME:	SWANER GUEST HOME II		FACILITY NUMBER:	275202805
ADMINISTRATOR:	MAGSAMBOL, MATTHEW		FACILITY TYPE:	740
ADDRESS:	978 ESTRADA COURT		TELEPHONE:	(831) 449-9379
CITY:	SALINAS	STATE: CA	ZIP CODE:	93907
CAPACITY:	6	CENSUS: 5	DATE:	10/03/2024
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Administrator, Mathew Magsambol		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff are not providing adequate food service
Staff are mismanaging resident's medication

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20241001165356

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: SWANER GUEST HOME II	FACILITY NUMBER: 275202805
	VISIT DATE: 10/03/2024

NARRATIVE

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Continued..

Regarding the allegation Staff are mismanaging resident's medication. Resident 1 has not been given a prescribed medication since 10/01/2024. Resident missed the 10/01/2024 dose, 10/02/2024 dose, and the 10/03/2024 dose. Based on records reviewed, and observation the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

This is an amended report.

The following deficiencies are being cited Per Title 22 Regulations

Exit interview conducted with Administrator Mathew Magsambol, and a copy of this report along with appeals rights provided.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20241001165356

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: SWANER GUEST HOME II	FACILITY NUMBER: 275202805
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/03/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/04/2024 Section Cited CCR 87555(a)(b)	1 2 3 4 5 6 7	87555 General Food Service Requirements(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner:(b) The following food service requirements shall apply: The following requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Administrator will conduct food safety, and proper food storage training with facility staff and submit proof to LPA by 10/24/2024. *This POC section was amended on 10/23/2024.
	8 9 10 11 12 13 14	LPA Hurt observed moldy food in the refrigerator, also food that requires refrigeration in the warm garage area, which poses an immediate health, safety, or personal rights risk to residents in care. v	8 9 10 11 12 13 14
Type B 10/17/2024 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. The following requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Administrator will conduct staff training on medication administration including documentation and submit to LPA by PO date of 11/06/2024. .*This POC section was amended on 10/23/2024.
	8 9 10 11 12 13 14	Resident 1 missed several doses of medication beginning 10/01/2024, which poses a potential, health, safety, or personal rghts risk to residents in care.	8 9 10 11 12 13 14

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: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC9099 (FAS) - (06/04)

Page: 3 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
10/01/2024 and conducted by Evaluator Sarah Hurt

COMPLAINT CONTROL NUMBER: 24-AS-20241001165356

FACILITY NAME:	SWANER GUEST HOME II		FACILITY NUMBER:	275202805
ADMINISTRATOR:	MAGSAMBOL, MATTHEW		FACILITY TYPE:	740
ADDRESS:	978 ESTRADA COURT		TELEPHONE:	(831) 449-9379
CITY:	SALINAS	STATE: CA	ZIP CODE:	93907
CAPACITY:	6	CENSUS: 5	DATE:	10/03/2024
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Administrator, Mathew Magsambol		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff did not maintain a comfortable temperature in the home

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility unannounced on October 3,2024 at 11:00 a.m. to investigate the above allegations. LPA met with facility Adminstrator Mathew Magsambol, and explained the purpose for today’s visit.

Regarding the allegation Staff did not maintain a comfortable temperature in the home. Reporting Party stated they observed the facility temperature to be 62 degrees, below required regulation. LPA Hurt observed the facility temperature to be 81 degrees, within regulation. Based on observation and interviews conducted during this investigation by Department of Social Services staff this allegation is UNSUBSTANTIATED. 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.

No deficincies cited today Per Title 22 Regulation. Exit interview conducted with Adminsitrator Mathew Magsambol, and a copy of this report provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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