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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006482
Report Date: 10/15/2024
Date Signed: 10/15/2024 02:40:38 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/20/2024 and conducted by Evaluator Dwayne L Mason
COMPLAINT CONTROL NUMBER: 22-AS-20240920154018
FACILITY NAME:GUARDIAN SENIOR HOME ON NEVADAFACILITY NUMBER:
306006482
ADMINISTRATOR:TRAN, EVANFACILITY TYPE:
740
ADDRESS:3327 NEVADA AVETELEPHONE:
(408) 693-8731
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:6CENSUS: 4DATE:
10/15/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Liza Moreno - CaregiverTIME COMPLETED:
02:55 PM
ALLEGATION(S):
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Facility issued residents an unlawful eviction
INVESTIGATION FINDINGS:
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Dwayne Mason Jr.
for the purpose of concluding the investigation into the above-mentioned complaint allegation. LPA
met with Caregiver (Lisa Moreno). LPA spoke with Administrator (AD) Evan Tran over the phone and discussed the purpose of the inspection. On 9/20/2024, the Department received a complaint stated the Facility issued residents an unlawful eviction.

On 9/23/2024 the Department conducted a case management visit to the facility and confirmed R1 underwent a medical and behavioral episode which led to high blood pressure in R1 and resulted in R1 hitting a staff member. On 9/23/2024, the Department received an email from the facility including the notice of the plan to evict. LPA obtained screenshots of the eviction notice issued to R1's responsible person. LPA noted that the notice was sent to the RP on 9/20/2024. LPA determined facility issued an unlawful eviction.

(continued on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 22-AS-20240920154018
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GUARDIAN SENIOR HOME ON NEVADA
FACILITY NUMBER: 306006482
VISIT DATE: 10/15/2024
NARRATIVE
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(continued from LIC9099)

On 9/30/2024, LPA conducted a visit to the facility. LPA conducted interviews with AD and staff. The AD and Staff stated R1 and R2 were verbally and physically aggressive toward staff members on multiple occasions. LPA obtained audio and video recordings of R1 and R2's behavior.

Based on interviews conducted and records reviewed, LPA determined the facility did not report any of the aggressive acts to staff that occurred from R1 and R2. A deficiency is being issued. LPA also reviewed the reporting requirements as stated in Component III with the facility staff and provided an electronic copy of the presentation.

Based on interviews conducted and records reviewed, LPA determined that due the facility issuing a same-day eviction notice to R1 without approval from the Department, the facility issued an unlawful eviction. Therefore, there is a preponderance of evidence to support the allegation of Facility issued resident an unlawful eviction.

The preponderance of evidence standard has been met. The allegation of Facility issued residents an unlawful eviction is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. An exit interview was conducted, and this report was reviewed with facility staff. A copy of this LIC-9099, deficiency page and appeal rights were provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20240920154018
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GUARDIAN SENIOR HOME ON NEVADA
FACILITY NUMBER: 306006482
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2024
Section Cited
CCR
87224(b)
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87224(b) EVICTION PROCEDURES (b) The licensee may, upon obtaining prior written approval from the licensing agency, evict the resident upon three (3) days written notice to quit. The licensing agency may grant approval for the eviction upon a finding of good cause.
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Adminsitrator stated they will conduct an in-service training with all staff regarding eviction procedures. AD stated they will document the topics covered, staff in attendance and date/time of the training. AD stated they will email LPA documentation related to training by the POC due date.
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Based on interviews conducted and records reviewed, the licensee did not comply with the above regulation due to the facility issuing a same-day eviction notice without prior written approval from the licensing agency.
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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.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3