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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247201317
Report Date: 10/27/2022
Date Signed: 10/27/2022 03:01:15 PM


Document Has Been Signed on 10/27/2022 03:01 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
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:
10/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:33 PM
MET WITH:Laura HuertaTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the Annual Inspection - Infection Control. Upon arrival, LPA contacted Administrator (AD) Lidia Silveira who authorized Caregiver, Laura Huerta to conduct the inspection and sign the report.

LPA toured the facility inside and out. Upon entry, LPA observed a posted visitor policy, visitor log/symptom screening and sanitizer. Covid-19 symptom and precautionary signs are posted at entry and throughout the facility. Furniture in common and dining areas are spaced to promote distancing. Facility has designated visitation areas available. LPA observed soap, paper towels and hand washing postings in bathrooms. LPA observed required food supply, paper products, 30-day PPE and resident medications. Cleaning/disinfecting products were locked. LPA reviewed resident emergency contact information. Fire and Carbon Monoxide alarms were observed in working order. Face covering requirements were reviewed with AD and staff.

AD stated that a report was submitted to CCLD in June 2022. AD is unsure if it was the Infection Control Plan (ICP). AD will email ICP to LPA or complete and submit one to LPA by 11/10/22. LPA provided an ICP template for reference. AD has agreed to revise the staff screening procedure to ensure compliance.

No deficiencies were cited during this inspection.

An exit interview was conducted. A copy of this report was left with designee Laura Huerta whose signature confirms receipt of these documents.


LPA requested the following updated forms by 11/10/22: LIC 308, LIC 400, LIC 402, LIC 500, LIC 610E,
LIC 9020, a copy of current Liability Coverage and Administrator Certificate.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
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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