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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275294362
Report Date: 12/06/2023
Date Signed: 12/06/2023 12:39:06 PM

Document Has Been Signed on 12/06/2023 12:39 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 HOMEFACILITY NUMBER:
275294362
ADMINISTRATOR:ROSARIO MAGSAMBOLFACILITY TYPE:
740
ADDRESS:18615 SWANER AVENUETELEPHONE:
(831) 449-9379
CITY:SALINASSTATE: CAZIP CODE:
93906
CAPACITY: 6CENSUS: 5DATE:
12/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee, Mathew MagsambolTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst's (LPA's) Sarah Hurt and Lisa Salazar arrived at the facility unannounced to conduct a Case Management visit. LPA's met with Administrator Matthew Magsambol and explained the purpose of todays visit.

LPA's observed slimy, and moldy carrots in the facility refrigerator. LPA's observed expired several bags of food in the facility refrigerator. LPA's observed ground beef on the facility stove clearly left out overnight. LPA's observed several room temperature perishable food items left out on the counter.

The following deficiencies are being cited Per Title 22 Regulations.

Exit interview conducted with Administrator Mathew Magsambol, and copy of this report provided.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2023
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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Document Has Been Signed on 12/06/2023 12:39 PM - It Cannot Be Edited


Created By: Sarah Hurt On 12/06/2023 at 11:36 AM
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: 12/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/07/2023
Section Cited
CCR
87555(b)

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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:
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Administrator Mathew Magsambol will audit facility food supply to ensure there is no expired food inside facility refrigerator and send proof to LPA by POC date of 12/07/2023.
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LPA's observed expired perishable food items in the facility refrigerator which poses an immediate. health, safety or personal rights risk to residents in care.
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Type B
12/20/2023
Section Cited
CCR87412(a)

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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:
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Administrator Mathew Magsambol will send S1's file to LPA by 12/20/2023 POC date.
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Staff 1 does not have Health Screeing Report LIC 503, or Criminal Records Statement LIC 508 in facility file which poses a potential health, safety, or personal rights risk to residents in care.
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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: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023


LIC809 (FAS) - (06/04)
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