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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006000
Report Date: 10/05/2021
Date Signed: 10/05/2021 12:46:44 PM

Document Has Been Signed on 10/05/2021 12:46 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GUARDIAN SENIOR HOME ON COMPASSFACILITY NUMBER:
306006000
ADMINISTRATOR:DO, KHANH KFACILITY TYPE:
740
ADDRESS:21302 COMPASS LNTELEPHONE:
(714) 679-2590
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY: 6CENSUS: 0DATE:
10/05/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator, Khanh DoTIME COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Jenifer Tirre visited this facility for the purpose of conducting a Pre-Licensing evaluation. No residents in care during time of visit. Facility is a single story residential home. LPA along with Administrator Khanh Do toured facility.

Fire clearance approval was received on 08/02/21. Structure: Facility is a one story, 6 bedroom (5 resident rooms 1 staff office) 3 bathroom house with an attached garage and a gray exterior. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: All Residents bedrooms meet Licensing requirements. Bathrooms: All resident bathrooms have a working toilet, wash basin, and bathtub/shower as well as grab bars and non-skid surface in the shower. Linens & Hygiene Supplies: Facility has adequate supply of linens and towels. Emergency Phone Numbers and Exit Plan: Facility has Emergency Plan posted on wall. Food Service: Facility has 7 day non-perishables in the pantry. Perishable food to be provided once facility receives residents. Emergency food and water supply on hand. Smoke Detectors: Smoke detectors/ carbon monoxide detector are centrally wired and were tested operational. Fire extinguisher is mounted and charged. Facility has 2 extinguishers. Facility has audible alarms on all sliding/exit doors. Appliances: Stove and refrigerator are operational. Toxins: LPA observed toxins secured in locked garage door. Water Temperature: Tested and recorded at 111.7 degrees F. in facility bathrooms. Reading Material Games, and Equipment:
facility has activities coordinator to do singing and exercises. Medications, First-Aid Kit & Book: Facility has first aid kit with manual present at the facility. Facility has a secured location for medications and facility files. Backyard: LPA observed the facility perimeter is secured by wall with a self latching gate on both sides of facility as required. LPA observed shaded outdoor seating.
CONTINUED ON 809C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GUARDIAN SENIOR HOME ON COMPASS
FACILITY NUMBER: 306006000
VISIT DATE: 10/05/2021
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Administrator's Certificate observed on wall expiring April 26,2023.

Component III Orientation was waived during this pre-licensing visit due to Administrator presently operating another facility.

No deficiencies noted during todays visit. The pre-licensing visit has been completed. This location is ready for licensure.


An exit interview was conducted with Administrator Khanh Do and a copy of report was left at facility
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
LIC809 (FAS) - (06/04)
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