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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202805
Report Date: 02/05/2025
Date Signed: 02/12/2025 01:53:39 PM

Document Has Been Signed on 02/12/2025 01:53 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
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SWANER GUEST HOME IIFACILITY NUMBER:
275202805
ADMINISTRATOR/
DIRECTOR:		MAGSAMBOL, MATTHEWFACILITY TYPE:
740
ADDRESS:978 ESTRADA COURTTELEPHONE:
(831) 449-9379
CITY:SALINASSTATE: CAZIP CODE:
93907
CAPACITY: 6CENSUS: 6DATE:
02/05/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Administrator, Mathew MagsambolTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analysts (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Mathew Magsambol, Continual Administrator's Certification for Rosario Magsambol expires for 06/20/2025. There are currently 6 residents who reside at this home and there is 0 residents on hospice at this time.

LPA reviewed 4 facility resident files, and 3 facility staff files. LPA reviewed residents funds, and resident medications. LPA reviewed Centrally Stored Medication Log for 3 facility residents.

Residents cash was not correctly logged (only February 2025 was accounted).

The facility temperature is 62 degrees.

Staff 1 does not have a Health Screening Report (LIC503) or required first aid training. Staff 2 does not have first aid training.

The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Administrator, Mathew Magsambol, and copy of report left at facility
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2025
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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Document Has Been Signed on 02/12/2025 01:53 PM - It Cannot Be Edited


Created By: Sarah Hurt On 02/05/2025 at 02:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
, CA

FACILITY NAME: SWANER GUEST HOME II
FACILITY NUMBER: 275202805

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in Staff 1 does not have required health screening/ TB, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2025
Plan of Correction
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4
Administrator Mathew Magsambol will send proof of staff 1 TB/ Health screening to LPA by POC date of 02/19/2025.
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in Staff1 does not have required first aid training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2025
Plan of Correction
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2
3
4
Administrator Mathew Magsambol will send proof of required first aid training for staff 1 to LPA by POC date of 02/19/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/12/2025 01:53 PM - It Cannot Be Edited


Created By: Sarah Hurt On 02/05/2025 at 02:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SWANER GUEST HOME II
FACILITY NUMBER: 275202805

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)(b)(1)
87303 Maintenance and Operation



(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

(b) A comfortable temperature for residents shall be maintained at all times.

(1) The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation,, the licensee did not comply with the section cited above in LPA observed facility temperature to be 62 degrees, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2025
Plan of Correction
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Administrator Mathew will conduct staff training on required facility temperature and submit proof to LPA by POC date of 02/19/2025.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Brenda Chan
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2025


LIC809 (FAS) - (06/04)
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