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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247201317
Report Date: 10/05/2021
Date Signed: 10/05/2021 12:07:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:GUARDIAN ANGEL HOME CAREFACILITY NUMBER:
247201317
ADMINISTRATOR:SILVEIRA, LIDIA FATIMAFACILITY TYPE:
740
ADDRESS:4345 VAUGHN AVENUETELEPHONE:
(209) 388-9447
CITY:MERCEDSTATE: CAZIP CODE:
95341
CAPACITY:5CENSUS: 4DATE:
10/05/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lidia SilveiraTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the Infection Control Inspection. LPA met with Administrator Lidia Silveira. LPA entered through the central entry point where hand sanitizer and screening was conducted.

Infection control procedures which were observed or reviewed by LPA include: Daily symptoms screenings (for staff, residents and visitors), testing, visitation, quarantine/isolation procedures, staffing, PPE and daily infection control procedures. Screening logs to be updated and emailed to LPA

LPA toured the facility inside and out. Required postings to encourage face coverings and hand washing were observed. Furniture in common and dining areas are spaced to promote distancing. Staff were observed wearing face coverings. Facility has multiple designated visitation areas available. LPA observed 30-day resident medication as well as PPE supply. Common and resident bathroom sinks are well stocked with liquid soap and paper towels for hand washing.

The following to be updated and submitted to LPA: LIC 610E, LIC 500, LIC9020, LIC 308 and proof of current Liability Insurance. Resident, Visitor and Staff Daily Health Screening logs to be updated and emailed to LPA by 10/12/21.


No deficiencies cited on today’s inspection.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
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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