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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006482
Report Date: 09/23/2024
Date Signed: 09/23/2024 05:44:43 PM

Document Has Been Signed on 09/23/2024 05:44 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: 4DATE:
09/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:45 PM
MET WITH:Evan Tran, TIME VISIT/
INSPECTION COMPLETED:
05:55 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit for the purpose of conducting a case management inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the purpose of the visit. Administrator Evan Tran was notified and interviewed via telephone.

On September 20, 2024, resident R1 was stated to have undergone a medical and behavioral episode which saw R1's blood pressure climb to 180 over 113 as well as hitting staff member S1. R1's blood pressure was reduced and 911 was called. After the 911 call, R1 hit staff member S2. R1's condition is stated to have improved while at the hospital however administrator declined to readmit the resident due to safety concerns for staff members and the four other residents. R1 was stated to reside at the facility with spouse R2. R1 was discharged to a new facility and R2 moved out earlier on the day of the present visit. Facility administrator was unable to provide information on the new facility where both were R1's assessment did not evidence any aggressive behavior upon admission. A copy of R1's resident records, medication administration records and staff notes for the months of August and September 2024 were obtained during the visit.

An exit interview was conducted via telephone and a copy of this report was provided to facility administrator.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2024
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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