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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006482
Report Date: 11/19/2024
Date Signed: 11/19/2024 11:30:10 AM

Document Has Been Signed on 11/19/2024 11:30 AM - 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:
11/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Liza Moreno - CaregiverTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 11/19/2024, LPA Mason arrived at the facility for the purpose of updated the LIC809D page issued to the facility on 9/20/2024 as part of the Department's investigation into complaint #22-AS-20240920154018.

LPA was greeted and granted entry into facility by Liza Moreno, Caregiver. LPA explained the purpose of the visit.

LPA amended the LIC809D page to remove the citation regarding reporting requirements. LPA explained to the facility staff that, the deficiency will remain attached to the Case Management visit conducted on 10/30/2024. LPA also explained that, the facility fulfilled the plan of corrections for the citation issued on 10/30/2024 and that no further action was required from the facility regarding that citation.

LPA reviewed this report with facility staff and provided a copy to the report as well as the amended LIC809D page.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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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