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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004794
Report Date: 08/05/2024
Date Signed: 08/05/2024 03:15:37 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/29/2024 and conducted by Evaluator Alvaro Ramirez Jr.
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240729141428
FACILITY NAME:GUARDIAN SENIOR HOMES ON MADISONFACILITY NUMBER:
306004794
ADMINISTRATOR:KHANH DOFACILITY TYPE:
740
ADDRESS:3080 MADISON AVENUETELEPHONE:
(800) 707-4939
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:6CENSUS: 6DATE:
08/05/2024
UNANNOUNCEDTIME BEGAN:
01:27 PM
MET WITH:Kaizan Mateo-CaregiverTIME COMPLETED:
03:31 PM
ALLEGATION(S):
1
2
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5
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7
8
9
Resident wandered away from the facility due to lack of care or supervision from staff.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced initial 10-Day complaint visit to initiate the investigation into the above allegation and to deliver the findings of the investigation. LPA was greeted and granted entry into the facility and met with Caregiver Kaizan Mateo. LPA explained the reason for the visit.

This agency has investigated the complaint alleging that resident wandered away from the facility due to lack of care and supervision. Regarding the allegation, the following was revealed: Two of two individuals interviewed denied the allegation. During the course of the interviews with the Reporting Party (RP), the RP confirmed that Resident 1 (R1) does not reside at 3080 Madison Ave Costa Mesa, CA 92626.
During the initial visit on August 5, 2024 LPA reviewed documents including the Register of Facility Clients/Residents dated February 10, 2024. Per Register of Facility Clients/Residents R1 is not a resident at Guardian Senior Homes on Madison.
CONTINUED ON LIC9099-C...
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 22-AS-20240729141428
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GUARDIAN SENIOR HOMES ON MADISON
FACILITY NUMBER: 306004794
VISIT DATE: 08/05/2024
NARRATIVE
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10
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32
Therefore, the allegation is deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis.

LPA Ramirez conducted an exit interview with caregiver Mateo, and a copy of this report was provided to the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2