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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
275294362
Report Date:
11/08/2024
Date Signed:
11/20/2024 01:02:12 PM
Document Has Been Signed on
11/20/2024 01:02 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
FACILITY NUMBER:
275294362
ADMINISTRATOR/
DIRECTOR:
ROSARIO MAGSAMBOL
FACILITY TYPE:
740
ADDRESS:
18615 SWANER AVENUE
TELEPHONE:
(831) 449-9379
CITY:
SALINAS
STATE:
CA
ZIP CODE:
93906
CAPACITY:
6
CENSUS:
3
DATE:
11/08/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
04:30 PM
MET WITH:
Administrator, Mathew Magsambol
TIME VISIT/
INSPECTION COMPLETED:
08:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Administrator Matthew Magsambol, Continual Administrator's Certification expires for Rosario Magsambol expires 06/21/2025. There are currently 3 residents who reside at this home and there is 0 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. There is a locked storage for medications. The facility has adequate 2 day perishable and 7 day non perishable food supply.
Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector. Water temperature was tested at 113 degrees. First Aid kit is on site and complete. LPA observed facility back window screen to be off the tracks and in disrepair. LPA observed facility hallway bathroom sink is plugged and fills with water. LPA observed resident back female resident bathroom vents to be extremely dirty. LPA observed several resident dressers in disrepair. LPA observed a hole under back female resident bathroom under the toilet. LPA observed hallway vent in disrepair and very dirty. LPA observed webs throughout facility, and dressers are dusty. LPA Hurt observed hallway bathroom trash with no lid. LPA observed meat covered in ice inside facility refrigerator frozen in a plastic container with only covered in foil. LPA observed sausages inside freezer with open with no covering. LPA Hurt observed dry fish in bottom refrigerator drawer with no label or date. LPA observed two dogs in the backyard one appeared to be very thing and not maintained. LPA observed disinfectant under the hallway bathroom cabinet accessible to residents.
Continued..
SUPERVISORS NAME
:
Brenda Chan
LICENSING EVALUATOR NAME
:
Sarah Hurt
LICENSING EVALUATOR SIGNATURE
:
DATE:
11/08/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/08/2024
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
8
Document Has Been Signed on
11/20/2024 01:02 PM
- It Cannot Be Edited
Created By:
Sarah Hurt
On
11/08/2024
at
07:35 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
FACILITY NUMBER:
275294362
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/08/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
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 CPR/first aid training, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
11/09/2024
Plan of Correction
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2
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4
Administrator Mathew Magsambol will send proof Staff 1 has required CPR/First aid training to LPA by POC date of 11/09/2024.
Type A
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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3
4
Based on record review, the licensee did not comply with the section cited above in staff 1 does not have required LIC503 Health Screening report, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
11/09/2024
Plan of Correction
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Administrator Mathew Magsambol will send proof to LPA of Staff 1's Health Screening report by POC date of 11/09/2024.
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:
11/08/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/08/2024
LIC809
(FAS) - (06/04)
Page:
2
of
8
Document Has Been Signed on
11/20/2024 01:02 PM
- It Cannot Be Edited
Created By:
Sarah Hurt
On
11/08/2024
at
07:35 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
FACILITY NUMBER:
275294362
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/08/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.
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 which LPA observed food inside refrigerator stored with no container or coverings, poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
11/09/2024
Plan of Correction
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2
3
4
Administrator will attend food service/storage training and submit proof to LPA by POC date of 11/09/2024.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
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:
Stephenie Doub
LICENSING EVALUATOR NAME:
Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE:
11/08/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/08/2024
LIC809
(FAS) - (06/04)
Page:
3
of
8
Document Has Been Signed on
11/20/2024 01:02 PM
- It Cannot Be Edited
Created By:
Sarah Hurt
On
11/08/2024
at
07:35 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
FACILITY NUMBER:
275294362
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/08/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
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.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in LPA observed webs throughout facility, and also resident back bedroom vents to be extremely dirty, large hole under back bedroom bathroom toilet, sink fixture in the back bedroom bathroom not working correctly, vents not on the wall correctly, and sink in hallway bathroom clogged, which poses/posed a potential health, safety or personal rigthts risk to persons in care.
POC Due Date:
11/22/2024
Plan of Correction
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Administrator will clean all vents, sink faucets, sinks, hole under toilet, and ensure all vent covers are on correctly, and submit proof to LPA by POC date of 11/22/2024.
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.
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 the side sliding glass door screen to be in disrepair and off track, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/22/2024
Plan of Correction
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Adminsitrator will fix window screen, and submit proof to LPA by POC date of 11/22/2024.
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:
11/08/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/08/2024
LIC809
(FAS) - (06/04)
Page:
4
of
8
Document Has Been Signed on
11/20/2024 01:02 PM
- It Cannot Be Edited
Created By:
Sarah Hurt
On
11/08/2024
at
07:35 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
FACILITY NUMBER:
275294362
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/08/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(f)(3)
Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in LPA observed bathroom trash with no lid,which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/22/2024
Plan of Correction
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2
3
4
Administator will ensure all facility trash bins have covers, and submit proof to LPA by POC date of 11/22/2024.
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in LPA observed disinfectant under hallway bathroom sink accessible to residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/22/2024
Plan of Correction
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Adminstrator will conduct training on safely handling and storing disinfectant, and send proof to LPA by POC date of 11/22/2024.
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:
11/08/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/08/2024
LIC809
(FAS) - (06/04)
Page:
5
of
8
Document Has Been Signed on
11/20/2024 01:02 PM
- It Cannot Be Edited
Created By:
Sarah Hurt
On
11/08/2024
at
07:35 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
FACILITY NUMBER:
275294362
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/08/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in LPA observed several meat items in refrigerator not covered properly, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/22/2024
Plan of Correction
1
2
3
4
Administrator will provide proof of food storage training to LPA by POC date of 11/22/2024.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in Administrator could not provide proof required quarterly disater drills, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/22/2024
Plan of Correction
1
2
3
4
Administrator will conduct quarterly disaster drills and send proof to LPA by POC date of 11/22/2024.
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:
11/08/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/08/2024
LIC809
(FAS) - (06/04)
Page:
6
of
8
Document Has Been Signed on
11/20/2024 01:02 PM
- It Cannot Be Edited
Created By:
Sarah Hurt
On
11/08/2024
at
07:35 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
FACILITY NUMBER:
275294362
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/08/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in Resident 1 does not have required annual medical assessment, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/22/2024
Plan of Correction
1
2
3
4
Administrator will provide updated LIC602 Physicians report for Resident 1 to LPA by POC date 11/22/2024.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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:
Stephenie Doub
LICENSING EVALUATOR NAME:
Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE:
11/08/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/08/2024
LIC809
(FAS) - (06/04)
Page:
7
of
8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION 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
FACILITY NUMBER:
275294362
VISIT DATE:
11/08/2024
NARRATIVE
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Continued..
Staff 1 does not have proof of first aid/CPR or LIC 503 Health screening form, and LIC 9052.
Resident 1 does not have updated Physicians report or Needs and services plan.
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 facility staff, Matthew Magsambol and copy of report left at facility
SUPERVISORS NAME
:
Brenda Chan
LICENSING EVALUATOR NAME
:
Sarah Hurt
LICENSING EVALUATOR SIGNATURE
:
DATE:
11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/08/2024
LIC809
(FAS) - (06/04)
Page:
8
of
8