<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275294362
Report Date: 10/03/2023
Date Signed: 10/17/2023 10:02:41 AM

Document Has Been Signed on 10/17/2023 10:02 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
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SWANER GUEST HOMEFACILITY NUMBER:
275294362
ADMINISTRATOR:ROSARIO MAGSAMBOLFACILITY TYPE:
740
ADDRESS:18615 SWANER AVENUETELEPHONE:
(831) 449-9379
CITY:SALINASSTATE: CAZIP CODE:
93906
CAPACITY: 6CENSUS: 6DATE:
10/03/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator, Mathew MagsambolTIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility unannounced on October 3, 2023 at 01:30 p.m.to conduct a Case Management visit. LPA met with facility Administrator Mathew Magsambol, and explained the purpose for today’s visit.

LPA Hurt observed San Andreas Regional Center liaisons at the facility also conducted a visit. LPA Hurt also observed Ombudsman present at the facility.

LPA Hurt observed cobwebs in the hallways, and corners of the bedrooms. LPA Hurt observed a large unmarked container with potato salad in the fridge with the expiration of 08/23/2023. LPA Hurt observed the potato salad to be old. LPA Hurt observed staff 1 does not have a Personnel file.


The following Deficiencies are being cited Per Title 22 Regulations.



Exit interview conducted with Administrator Mathew Magsambol, and a copy of this report provided.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/17/2023 10:02 AM - It Cannot Be Edited


Created By: Sarah Hurt On 10/03/2023 at 01:52 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
FACILITY NUMBER: 275294362

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/17/2023
Section Cited
CCR
87555(b)

1
2
3
4
5
6
7
GENERAL FOOD SERVICE REQUIREMENTS.
87555(b)All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. The following requirement has not been met as evidenced by:
1
2
3
4
5
6
7
Administrator agrees to conduct staff training on food safety and contamination and submit proof to LPA by 10/17/2023.
8
9
10
11
12
13
14
LPA Hurt observed large container of expired potato salad in the fridge marked 08/23/2023 which contains a potential health, safety, or personal rights risk to residents in care.
8
9
10
11
12
13
14
Type B
10/17/2023
Section Cited
CCR87412(a)

1
2
3
4
5
6
7
87412 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: The following requirement has not been met as evidenced by:
1
2
3
4
5
6
7
Administrator will provide Personnel records for Staff 1 to LPA Hurt by 10/17/2023.
8
9
10
11
12
13
14
Staff 1 has been working at the facility and is fingerprint cleared, but does not have a Personnel record which poses a potential, health, safety, or personal rights 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.
SUPERVISOR'S NAME:Brenda Chan
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2