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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275294362
Report Date: 11/22/2025
Date Signed: 12/01/2025 08:45:04 AM

Document Has Been Signed on 12/01/2025 08:45 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/
DIRECTOR:		ROSARIO MAGSAMBOLFACILITY TYPE:
740
ADDRESS:18615 SWANER AVENUETELEPHONE:
(831) 449-9379
CITY:SALINASSTATE: CAZIP CODE:
93906
CAPACITY: 6CENSUS: 3DATE:
11/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Administrator Matthew Magsambol, and facility staff Sara MagsambolTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Database Link IconLicensing Program Analysts (LPA's) Sarah Hurt and Shawna Doucette conducted an unannounced visit today for the facility’s annual inspection. LPA met with facility staff, Matthew Magsambol, and Sarah Magsambol, Continual Administrator's Certification for Licensee Rosario Magsambol expires 06/20/2027. 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.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 107 degrees.

LPA's observed the facility vent in hallway resident bathroom is dirty and falling off the ceiling. LPA observed the back sliding window screen with tears, and not in good repair. LPA observed the back side patio had multiple dog feces on the ground. LPA stepped in dog feces while touring the facility backyard. LPA observed the back patio had trash and furniture broken bedroom furniture. LPA observed the back patio had no shaded area for residents. LPA observed the facility back resident bedroom faucet in disrepair, and front hallway resident bathroom sink does not drain properly. LPA observed resident bedroom dresser furniture in disrepair. First Aid kit is on site and only missing the antiseptic solution.
NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: Sarah Hurt
LICENSING PROGRAM ANALYST SIGNATURE: DATE:
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE:
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 20
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 20
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: 11/22/2025
NARRATIVE
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LPA's observed female resident linens ripped. LPA's observed cleaning supplies including bleach in resident bedroom. LPA observed the facility hallway to the right of the entrance smells of animal and animal urine.

Facility has a staff refrigerator/freezer with eggs that have no date as to how long the eggs have been in the refrigerator. Staff and resident food are mixed and it is unknown what food belongs to residents and what food belongs to staff. LPA's observed expired food, food in freezer that is open, no dates on food, and unknown items of food in unmarked containers. LPA's observed open packages of crab and meats in freezer. Spaghetti and other food requiring refrigeration was out on the counter and was room temperature. Staff stated it's been out since this morning and was still out during visit at at 2:30 PM. Facility did not have a 2 day perishable food supply. LPA's did not observe any milk or eggs in facility resident refrigerator. Facility did not have a 7 day non perishable food supply. LPA's observed a total of approximately 6 canned foods. LPA's observed several expired soups in pantry area.

R1 is missing 2 medications that were not refilled. R1 last took the medication on 11/15/25. R1 does not have a pre admission appraisal, functional capabilities assessment or a LIC602. The facility staff does not have required training.

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.

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

Exit interview conducted with Facility Staff Matthew, Magsambol, and copy of report left at facility
NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: Sarah Hurt
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2025
LIC809 (FAS) - (06/04)
Page: 3 of 20
Document Has Been Signed on 12/01/2025 08:45 AM - It Cannot Be Edited


Created By: Sarah Hurt On 11/22/2025 at 03:22 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: 11/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation the licensee did not comply with the section cited above in LPA's observed cleaning solutions including bleach inside residents bedroom, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/23/2025
Plan of Correction
1
2
3
4
Licensee will conduct training on ensuring chemicals, and cleaning solutions are not accessible to residents and submit to LPA by POC date of 11/23/2025.
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation. and record review, the licensee did not comply with the section cited above in Resident 1 has not been given several doses of prescribed medication, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/23/2025
Plan of Correction
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Licensee will submit proof of refills of all Resident 1's prescribed medications, and submit proof to LPA by POC date of 11/23/2025. LPA will return to facility to confirm deficiency is cleared.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephenie Doub
NAME OF LICENSING PROGRAM MANAGER:
Sarah Hurt
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2025


LIC809 (FAS) - (06/04)
Page: 4 of 20
Document Has Been Signed on 12/01/2025 08:45 AM - It Cannot Be Edited


Created By: Sarah Hurt On 11/22/2025 at 03:22 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: 11/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
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.

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's observed facility backyard with old furniture and junk to be removed, animal feces in side area of backyard, hallway to the right of entrance smells of animal urine, facility bathroom vent is dirty, and hanging off the ceiling, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2025
Plan of Correction
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3
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Licensee will clean the facility inside and outside and submit proof to LPA by POC date of 12/06/2025.
Type B
Section Cited
CCR
87307(a)(3)(B)
Personal Accommodations and Services
(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in LPA's observed facility resident bedroom dressers are not in good repair, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2025
Plan of Correction
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Licensee will repair or purchase new resident bedroom furniture and submit proof to LPA by POC date of 12/06/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephenie Doub
NAME OF LICENSING PROGRAM MANAGER:
Sarah Hurt
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2025


LIC809 (FAS) - (06/04)
Page: 5 of 20
Document Has Been Signed on 12/01/2025 08:45 AM - It Cannot Be Edited


Created By: Sarah Hurt On 11/22/2025 at 03:22 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: 11/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(C)
Personal Accommodations and Services
(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited.

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 resident female bedroom pink sheets are ripped and not in good repair, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2025
Plan of Correction
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Licensee will change sheets and submit proof to LPA by POC date of 12/06/2025.
Type B
Section Cited
CCR
87405(d)
Adminstrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.

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's observed multiple citings and the facility is out of compliance with licensing regulations, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2025
Plan of Correction
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2
3
4
Licensee / Administrator will submit a written plan on how the facility will come into compliance with all Title 22 Regulations and submit to LPA by POC date of 12/06/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephenie Doub
NAME OF LICENSING PROGRAM MANAGER:
Sarah Hurt
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2025


LIC809 (FAS) - (06/04)
Page: 6 of 20
Document Has Been Signed on 12/01/2025 08:45 AM - It Cannot Be Edited


Created By: Sarah Hurt On 11/22/2025 at 03:22 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: 11/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(d)
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee did not have staff training for all staff to meet training requirements, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2025
Plan of Correction
1
2
3
4
Licensee agrees to submit copies of staff training for all staff to meet all RCFE training regulations by POC due date 12/12/25.
Section Cited
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
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.
Stephenie Doub
NAME OF LICENSING PROGRAM MANAGER:
Sarah Hurt
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2025


LIC809 (FAS) - (06/04)
Page: 7 of 20
Document Has Been Signed on 12/01/2025 08:45 AM - It Cannot Be Edited


Created By: Sarah Hurt On 11/22/2025 at 03:22 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: 11/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in LPA's observed food items in refrigerator without labels and crab and meats inside damaged packages,which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2025
Plan of Correction
1
2
3
4
Licensee will immediately dispose of all food items in damaged or open containers, and expired foods.Licensee wll retrain staff on safe fod handling practices including packaging integrity upon delivery and during weekly inspections and submit proof to LPA's by POC date of 12/06/2025.
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's observed spaghetti and other perishable foods on kitchen counter at room temperature, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2025
Plan of Correction
1
2
3
4
Licensee will re train staff on proper storage of perishable foods including maintaining appropriate temperatures and submit proof to LPA's by POC date of 12/06/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephenie Doub
NAME OF LICENSING PROGRAM MANAGER:
Sarah Hurt
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2025


LIC809 (FAS) - (06/04)
Page: 8 of 20
Document Has Been Signed on 12/01/2025 08:45 AM - It Cannot Be Edited


Created By: Sarah Hurt On 11/22/2025 at 03:22 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: 11/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

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 facility does not have required one week perishable food supply,which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2025
Plan of Correction
1
2
3
4
Licensee will purchase required minimum one week perishable food supply and submit to LPA by POC date of 12/06/2025.
Type B
Section Cited
CCR
87555(b)(28)
General Food Service Requirements
(b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.

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's observed spaghetti and other foods out on facility counter at room temperature, crab and other meat products open and exposed inside facility freezer, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2025
Plan of Correction
1
2
3
4
Licensee will submit written statement of understanding on how to properly store foods and submit to LPA's by POC date of 12/06/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephenie Doub
NAME OF LICENSING PROGRAM MANAGER:
Sarah Hurt
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2025


LIC809 (FAS) - (06/04)
Page: 9 of 20
Document Has Been Signed on 12/01/2025 08:45 AM - It Cannot Be Edited


Created By: Sarah Hurt On 11/22/2025 at 03:22 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: 11/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
1
2
3
4
Type B
Section Cited
CCR
87506(b)(15)
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

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 pre admission appraisal, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2025
Plan of Correction
1
2
3
4
Licensee will submit Pre admission assesment for resident 1 to LPA's by POC date of 12/06/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephenie Doub
NAME OF LICENSING PROGRAM MANAGER:
Sarah Hurt
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2025


LIC809 (FAS) - (06/04)
Page: 10 of 20
Document Has Been Signed on 12/01/2025 08:45 AM - It Cannot Be Edited


Created By: Sarah Hurt On 11/22/2025 at 03:22 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: 11/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

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 a completed medical assesment, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2025
Plan of Correction
1
2
3
4
Licensee will submit Resident 1's Physician Report to LPA's for review by poc date of 12/06/2025.
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.
Stephenie Doub
NAME OF LICENSING PROGRAM MANAGER:
Sarah Hurt
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2025


LIC809 (FAS) - (06/04)
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