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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247203432
Report Date: 01/06/2021
Date Signed: 01/06/2021 01:04:22 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 CARE IIFACILITY NUMBER:
247203432
ADMINISTRATOR:SILVEIRA, LIDIAFACILITY TYPE:
740
ADDRESS:194 CLIPPER COURTTELEPHONE:
(209) 605-5239
CITY:ATWATERSTATE: CAZIP CODE:
95301
CAPACITY:6CENSUS: 5DATE:
01/06/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:12 PM
MET WITH:Licensee, Lidia SilveiraTIME COMPLETED:
01:00 PM
NARRATIVE
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On 01/06/2021, Licensing Program Analyst (LPA) contacted Licensee, Lidia Silveira to conduct a Case Management - Deficiencies visit via telephone due to COVID-19 and precautionary measures. LPA introduced self and explained the purpose of the call.

During the course of a complaint investigation, it was found that the facility did not submit Incident Reports to the Department as required.

A deficiency is being cited in accordance with the California Code of Regulations, Title 22, Division 6, Chapter 8, 87211(a)(1)(D).

An exit interview was conducted and a Plan of Correction was reviewed and developed with Licensee. A copy of this report and appeal rights were provided to the Licensee via email and an electronic read receipt confirms receiving these documents. Facility Representative signature on file.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/11/2021
Section Cited

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87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency... (1) written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the
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occurrence of... (D)Any incident which threatens the welfare, safety or health of any resident... This requirement was not met as evidenced by: Licensee did not submit reports to the Department. This poses a potential threat to the health and safety of clients in care.
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facility plan to ensure incidents are reported to the Fresno CCL office will by submitted by 1/11/2021.

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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: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2021
LIC809 (FAS) - (06/04)
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