247203432-1-6-2021-24-AS-MHON-BX9RJD-20210114120345

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 247203432
Report Date: 01/06/2021
Date Signed: 01/06/2021 01:09:26 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
04/02/2020 and conducted by Evaluator Alexandria Walton

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20200402102001

FACILITY NAME:	GUARDIAN ANGEL HOME CARE II		FACILITY NUMBER:	247203432
ADMINISTRATOR:	SILVEIRA, LIDIA		FACILITY TYPE:	740
ADDRESS:	194 CLIPPER COURT		TELEPHONE:	(209) 605-5239
CITY:	ATWATER	STATE: CA	ZIP CODE:	95301
CAPACITY:	6	CENSUS: 4	DATE:	01/06/2021
		UNANNOUNCED	TIME BEGAN:	10:37 AM
MET WITH:	Licensee, Lidia Silveira		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not provide a safe environment for resident

INVESTIGATION FINDINGS:

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

On 1/06/2021, Licensing Program Analyst (LPA) A. Walton contacted Licensee, Lidia Silveira to deliver findings on the above allegation via telephone due to COVID-19 and precautionary measures. LPA introduced self and discussed the purpose of the call with the Licensee.

LPA conducted interviews with residents and staff and reviewed records. During an interview with R1, R1 confirmed verbally and physically assaulting resident R2. Interviews with staff revealed that R1 was aggressive to both residents and staff while in the facility.

Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
CONTINUED TO LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 24-AS-20200402102001

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: 01/06/2021

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

Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D.

An exit interview was conducted with Licensee and the 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 Hoffmann	TELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 24-AS-20200402102001

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: 01/06/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/11/2021 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities: (a) Residents...shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations...	1 2 3 4 5 6 7	Licensee will submit a detailed report outlining steps that the facility will take to esnure all residents are accorded safe accommodations by 1/11/2021.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: R1 confirmed physically assaulting R2 on multiple occassions. This poses an immediate health and safety risk to clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Hoffmann	TELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 3 of 3