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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247203432
Report Date: 07/10/2020
Date Signed: 07/10/2020 01:26:13 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
03/30/2020 and conducted by Evaluator Alexandria Walton
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20200330110632
FACILITY NAME:GUARDIAN ANGEL HOME CARE IIFACILITY NUMBER:
247203432
ADMINISTRATOR:SILVEIRA, LIDIAFACILITY TYPE:
740
ADDRESS:194 CLIPPER COURTTELEPHONE:
(209) 605-5239
CITY:ATWATERSTATE: CAZIP CODE:
95301
CAPACITY:6CENSUS: 5DATE:
07/10/2020
UNANNOUNCEDTIME BEGAN:
10:56 AM
MET WITH:Administrator, Lidia SilveiraTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident sustained pressure injury while in care.
INVESTIGATION FINDINGS:
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On 07/10/2020, Licensing Program Analyst (LPA), A. Walton conducted a Tele-Visit with Administrator, Lidia Silveira to deliver findings on the above stated allegation.

Based on interviews and review of records the care home accepted and retained a resident who had a Prohibited Health condition, a stage III pressure injury, without requesting an exception from CCL. Licensee acknowledges that the resident had a stage III pressure injury and did not seek medical treatment as they felt that they could take care of pressure injury themselves. The care home did not receive an exception for this resident as required per regulations, therefore, the resident should have been transferred to a higher level of care for treatment.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2020
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 3
Control Number 24-AS-20200330110632
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 II
FACILITY NUMBER: 247203432
VISIT DATE: 07/10/2020
NARRATIVE
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Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D during this visit. An immediate Civil Penalty is being assessed in the amount of $500 in accordance with California Code of Regulations, Title 22. Exit interview held, Appeal Rights discussed, copy of report given via email and an electronic read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20200330110632
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 II
FACILITY NUMBER: 247203432
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2020
Section Cited
CCR
87615(a)(1)
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87615(a)(1) Prohibited Health Conditions. Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care...
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Adminstrator will submit documentation detailing a plan to train staff on pressure injuries and Prohibited Health Conditions to ensure resident needs are being met to the Fresno CCL office by 07/13/2020.
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facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by:
On 3/2/2020, R1 was admitted to the hospital with a Stage 3 pressure injury. Facility accepted R1 back to the facility with this prohibited condition and on 3/27/2020, R1 was re-admitted to the hospital with worsening of this pressure injury and two other pressure injuries that were unstageable and required debridement. This posed an immediate health and safety risk to the resident.
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Administrator stated that staff will be trainied on pressure injuries and Prohibited Health Conditions. Documentation of training topics and attendance will be submitted to the Fresno CCL office by 07/27/2020
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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: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3