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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006000
Report Date: 10/25/2024
Date Signed: 10/25/2024 01:33:46 PM

Document Has Been Signed on 10/25/2024 01:33 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 HOME ON COMPASSFACILITY NUMBER:
306006000
ADMINISTRATOR/
DIRECTOR:		DO, KHANH KFACILITY TYPE:
740
ADDRESS:21302 COMPASS LNTELEPHONE:
(714) 679-2590
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY: 6CENSUS: 5DATE:
10/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:00 AM
MET WITH:Caregiver, Ali JohnsonTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On 10/25/2024, Licensing Program Analyst's (LPA's) Jenifer Tirre and Eboni Bentley conducted an unannounced required visit using the CARE Inspection Tool. LPA's were greeted by staff and granted entry after stating the purpose of the visit. Administrator (Admin) Kai Mateo was not present to assist with the facility inspection on today's date.

The facility is licensed for six (6) non-ambulatory residents with approved hospice waiver for three (6) residents. Currently, there are one (1) Hospice resident present during today’s visit.

This is a single story with a two-car garage facility. The facility has six bedrooms (4 private resident rooms, 1 shared resident room and 1 staff room) , and three full bathrooms.

At around 8:20, LPA's conducted a tour of the physical plant accompanied by caregiver, and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured between 105.8 to 108.6 degrees F. was maintained in the facility.



LPA's observed the facility to be furnished at the time of the visit. Storage areas for toxins and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Facility has emergency food and water supply. Facility has two fire extinguishers and fire extinguishers was mounted and fully charged. A review of the Medication Records Administration (MAR) was conducted, and LPA observed the records are in compliance.


CONTINUED ON 809C
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GUARDIAN SENIOR HOME ON COMPASS
FACILITY NUMBER: 306006000
VISIT DATE: 10/25/2024
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During the visit, LPA's observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. The last fire drill was conducted on June 1, 2024. The facility had operational smoke and carbon monoxide detectors in bedrooms and common areas. The facility is current on Community Care Licensing annual dues.

A review of five residents (R1-R5) service files and three staff (S1-S3) personnel files revealed to be complete. The facility has the current administrator's certification on file for Knanh Do Expiration 04/26//2025.

No deficiencies during this inspection visit.

An exit interview was conducted with Staff, and a copy of the report was provided.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC809 (FAS) - (06/04)
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