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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006482
Report Date: 08/09/2024
Date Signed: 08/09/2024 02:42:06 PM

Document Has Been Signed on 08/09/2024 02:42 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 NEVADAFACILITY NUMBER:
306006482
ADMINISTRATOR/
DIRECTOR:		TRAN, EVANFACILITY TYPE:
740
ADDRESS:3327 NEVADA AVETELEPHONE:
(408) 693-8731
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 6DATE:
08/09/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Evan Tran, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made a scheduled visit to the facility for the purpose of conducting a pre-licensing inspection. LPA was greeted and granted entry by Evan Tran, administrator.

An initial application for a license to operate as a Residential Care Facility for the Elderly was received by the Department on December 18, 2023 for a capacity of six non-ambulatory residents. This is a change of ownership with six residents already in care. None of the currently admitted individuals are receiving hospice care. The applicant has requested a hospice waiver for six residents.

LPA accompanied by administrator toured the physical plant. The facility is a one-level home with a frontyard, backyard and attached garage. There are two shared bedrooms and two private bedrooms with one shared bathroom, one en-suite bathroom accessible from the shared master bedroom and a powder room next to the common living area. Each of the bedrooms include all necessary components of furnishing including a light, chair, storage space for personal items and a full-size bed as well as a supply of linen and bedsheets. Water temperature was measured at 110F, which is within the required range. Common living spaces are present and an internet connection is present for the use of the residents in care. Facility is clean, sanitary and free of odors in all areas inspected. Required posted documents are observed to be present.

Kitchen equipment is present and operating as required. Sharp items and cleaning supplies are confirmed to be secured. A sufficient supply of perishable and non-perishable food is present as required by Title 22 Regulations. The centrally stored medication storage is located in a secure cabinet with a key lock. LPA provided applicant with a consultation on pre-pouring of medication. The garage is used for additional storage of food along with emergency and back-up supplies along with a laundry area. The entrance to the garage is also secured with a digital lock.
CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2024
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 NEVADA
FACILITY NUMBER: 306006482
VISIT DATE: 08/09/2024
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CONTINUED FROM FORM LIC809

Staff and six client records were reviewed and confirmed to include all necessary components. The fire clearance has been obtained and provided to the Department prior to the pre-licensing visit. Combined smoke and carbon monoxide detectors are observed throughout the facility and confirmed to be functional. Fire extinguishers present on the premises are observed to be charged with current maintenance tags. First aid kit verified to be complete.

LPA and licensee toured the outside of the facility and observed it to be free of obstructions. One shaded area is present in the backyard and is equipped with outdoor furniture for the enjoyment of residents and visitors. The perimeter gates present on one side of the premises is self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.

Component III was waived as the prospective licensee has already been acting as the current facility administrator and operates other licensed locations as well. This report was reviewed with facility representative and a copy of this report was emailed to the prospective licensee before the conclusion of the visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC809 (FAS) - (06/04)
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