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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006000
Report Date: 12/17/2025
Date Signed: 12/17/2025 05:19:31 PM

Document Has Been Signed on 12/17/2025 05:19 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: 6DATE:
12/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Caregiver- Ali JohnsonTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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On December 17, 2025, at 1:45 PM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by Caregiver (CG) Ali Johnson. LPA Kim spoke with Administrator (ADMIN) Khanh Do over the phone and explained the purpose of the visit. ADMIN Do stated that they could not make today’s visit and CG Johnson could sign on behalf of the facility.

The facility is licensed to operate for six (6) nonambulatory residents and have a hospice waiver for six (6) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, an office, three (3) bathrooms, living area, dining area, kitchen, outdoor covered patio, and an attached two car garage.

LPA Kim toured inside and outside of the physical plant with CG Johnson. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, and Resident Room 5. Bathrooms were clean and operational. The water temperature measured at 126.8 degrees F to 129.0 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility. LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents.

Evaluation Report Continues on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Edward Kim
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2025
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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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)
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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: 12/17/2025
NARRATIVE
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The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food, emergency water, and emergency supplies were stored in the garage. The facility has two (2) fire extinguisher that are charged and mounted in the kitchen and in the resident hallway across from resident room 1 and was last inspected on December 3, 2025.

During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The PUB475 poster at the facility was measured at 10.75” X 16.0” instead of the required 20” X 26”. The smoke detectors and carbon monoxide detectors were operable. First Aid kit had all the necessary elements. A working telephone (714274-9989) remains available. Certificate of Liability Insurance was effective from October 25, 2025, to October 25, 2026. At the time of the visit, the latest Emergency Drill log that was available at the facility stated that emergency drill was last conducted on May 20, 2025.

LPA Kim conducted an audit of resident files (R1-R6), staff files (S1-S5), and medication and medication administration record. LPA observed the following on R1-R5’s reappraisal: R1’s latest reappraisal was conducted on July 24, 2024, R2’s latest reappraisal conducted was conducted on September 19, 2023, R3’s latest reappraisal conducted was on November 2, 2023, R4’s latest reappraisal was conducted on August 28, 2024, and R5’s latest reappraisal was conducted on November 21, 2024. LPA observed that following for staff Training hours for 2025: S1 completed 18 hours, S2 completed 18 hours, S3 completed 16 hours, and S4 completed 16 hours. LPA Kim conducted interviews with two (2) residents and one (1) staff.

Deficiencies were cited during this visit as per Title 22 Division 6 Chapter 8 of the California Code of
Regulations. LPA observed water temperature from bathroom #1 measured at 129.0 degrees F, bathroom #2 measured at 126.8 degrees F, and bathroom #3 measured at 127.9 degrees F. LPA observed the following reappraisals not conducted within 12 months: R1’s reappraisal was dated on 7/24/2024, R2’s reappraisal was dated on 9/19/2023, R3’s reappraisal was dated on 11/2/2023, R4’s reappraisal was dated on 8/28/2024, and R5’s reappraisal was dated on 11/21/2024. LPA observed the last emergency drill was conducted on May 20, 2025.
Evaluation Report Continues on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Edward Kim
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/17/2025 05:19 PM - It Cannot Be Edited


Created By: Edward Kim On 12/17/2025 at 04:41 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GUARDIAN SENIOR HOME ON COMPASS
FACILITY NUMBER: 306006000

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in three out of three bathroom sinks. Hot water temperature measured in Bathroom #1 at 129.0 degrees F, Bathroom#2 at 126.8 degrees F, and bathroom #3 at 127.9 degrees F. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/18/2025
Plan of Correction
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Licensee stated they will fix the temperature to be within regulation and send proof of a photo measuring the temperature being in range and keep a water log that measures the water temperature every 2 hours for a 24 hour period to CCLD via email to edward.kim@dss.ca.gov by POC due date December 18, 2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Edward Kim
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/17/2025 05:19 PM - It Cannot Be Edited


Created By: Edward Kim On 12/17/2025 at 04:41 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GUARDIAN SENIOR HOME ON COMPASS
FACILITY NUMBER: 306006000

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA observed R1's latest appraisal was dated July 24, 2024, R2's latest appraisal was dated September 19, 2023, R3's latest appraisal was dated November 2, 2023, R4's latest appraisal was dated August 28, 2024, and R5's latest appraisal was dated November 21, 2024 This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/31/2025
Plan of Correction
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Licensee states they will send updated reappraisals for R1, R2, R3, R4, and R5 to CCLD via email to edward.kim@dss.ca.gov by POC due date December 31, 2025.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA observed last emergency drill on file available during the visit was conducted on May 20, 2025, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/31/2025
Plan of Correction
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Licensee states they will send a current emergency drill for this quarter and send a tentative schedule of emergency drills for 2026 to CCLD via email to edward.kim@dss.ca.gov by POC due date December 31, 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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Edward Kim
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2025


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: 12/17/2025
NARRATIVE
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 Technical violations were issued during the visit. LPA Kim observed Staff did not completed 20 hours of training: S1 completed 18 hours of training, S2 completed 18 hours of training, S3 completed 16 hours of training, and S4 completed 16 hours of training. LPA Kim observed PUB475 poster measured at 10.75” X 16.0” instead of the mandatory 20” X 26”.

An exit interview was conducted, and a copy of this report, LIC811, LIC9102, and appeal rights were provided to Caregiver Ali Johnson.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Edward Kim
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025
LIC809 (FAS) - (06/04)
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