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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004794
Report Date: 03/11/2025
Date Signed: 03/11/2025 03:22:35 PM

Document Has Been Signed on 03/11/2025 03:22 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GUARDIAN SENIOR HOMES ON MADISONFACILITY NUMBER:
306004794
ADMINISTRATOR/
DIRECTOR:		KHANH DOFACILITY TYPE:
740
ADDRESS:3080 MADISON AVENUETELEPHONE:
(800) 707-4939
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 5DATE:
03/11/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:05 PM
MET WITH:Joe MateoTIME VISIT/
INSPECTION COMPLETED:
03:37 PM
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Licensing Program Analyst (LPA) Fred Arias made an unannounced visit for the purpose of conducting a Plan of Corrections Inspection for a deficiency issued on 02/05/2025 during the required annual inspection. LPA was greeted and granted entry by staff Joe Mateo . LPA discussed the purpose of the inspection with staff.
LPA toured the facility to check the deficiency has been corrected with staff Mateo. LPA observed no cameras on the second floor.
Based on LPA's observation on today's visit, the Plan of Corrections has been fulfilled by the assigned POC due date of 02/19/2025, thus clearing the Type B deficiency CCR 87468.1(a)(2).
An exit interview was conducted with staff Mateo and a copy of this report was provided to the facility representative.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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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