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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006482
Report Date: 10/30/2024
Date Signed: 10/30/2024 03:22:09 PM

Document Has Been Signed on 10/30/2024 03:22 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 ASC, 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:
10/30/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Allison Ramirez - CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 10/30/2024, LPA Mason arrived at the facility unannounced for the purpose of issuing a citation based on observations made during a complaint investigation.

During the investigation, it was determined that the facility did not file incident reports for instances of residents engaging in aggressive behavior toward staff. LPA advised facility staff of reporting requirements.

Based on today's inspection, one citation is being issued. The facility fulfilled the plan of correction on 10/21/2024. LPA reviewed this report with facility staff. A copy of this report and plan of correction clear letter were provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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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Document Has Been Signed on 10/30/2024 03:22 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 10/30/2024 at 03:13 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 NEVADA
FACILITY NUMBER: 306006482

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2024
Section Cited
CCR
87211(a)(1)(D)

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87211(A)(1)(D) REPORTING REQUIREMENTS (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of...(D) Any incident which threatens the welfare, safety or health of any resident.
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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 not reporting aggressive acts to staff by a resident.
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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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024


LIC809 (FAS) - (06/04)
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