247201317-10-5-2021-24-AS-SPIY-C86PQ6-20211026113034

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 247201317
Report Date: 10/05/2021
Date Signed: 10/05/2021 02:14:48 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/23/2021 and conducted by Evaluator Katie Brown

COMPLAINT CONTROL NUMBER: 24-AS-20210623152119

FACILITY NAME:	GUARDIAN ANGEL HOME CARE		FACILITY NUMBER:	247201317
ADMINISTRATOR:	SILVEIRA, LIDIA FATIMA		FACILITY TYPE:	740
ADDRESS:	4345 VAUGHN AVENUE		TELEPHONE:	(209) 388-9447
CITY:	MERCED	STATE: CA	ZIP CODE:	95340
CAPACITY:	5	CENSUS: 4	DATE:	10/05/2021
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Lidia Silveira		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not allow the residents to walk while in care
Staff inappropriately restrain the residents while in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unnanounced to conduct a subsequent visit. LPA Met with Administrator Lidia Silveira. LPA reviewed the allegations and discussed the purpose of the visit.

During the visit, LPA conducted interviews and toured the facility. LPA reviewed and obtained information from R1's facility file.

The Department has investigated the complaint alleging: Staff do not allow the residents to walk while in care. LPA observed a resident (not R1) at the facility ambulating with staff assistance upon arriving to the facility unannounced. Based on interview, visiting nurses have observed R1 walking with a walker or with staff’s assistance before and after the incident. Based on record review of IDT Note dated 7/8/21, R1 requires assistance when ambulating, staff provides continuous supervision for safety. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. The allegation is UNSUBSTANCIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 24-AS-20210623152119

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: GUARDIAN ANGEL HOME CARE	FACILITY NUMBER: 247201317
	VISIT DATE: 10/05/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The Department has investigated the complaint alleging: Staff inappropriately restrain the residents while in care. Based on record Review of IDT note dated 7/8/21, there were no signs of restraints noted. Based on interviews of facility staff, R1, Administrator and visiting nurses there is no evidence that R1 was restrained in the facility. None of the individuals interviewed state that they have ever seen R1 restrained white visiting the facility. While touring the facility, LPA did not observe any items attached to resident beds or wheel chairs. Nothing was observed by the LPA that suggested restraints were being used. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. The allegation is UNSUBSTANTIATED.

No deficiencies were cited on todays visit.

A copy of this report was provided and an exit interview were conducted with the Administrator

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 2