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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247203432
Report Date: 01/26/2022
Date Signed: 01/26/2022 03:22:23 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:
01/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Cargiver, Maria FernandezTIME COMPLETED:
01:55 PM
NARRATIVE
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On 01/26/2022 at approximately 10:11AM, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit and was granted entry to the facility by Caregiver, Maria Fernandez. LPA requested to meet with the Administrator. Caregiver contacted Administrator via phone. Administrator was not able to attend this inspection, LPA received verbal permission to meet with Caregiver.

COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Facility tour conducted with Caregiver. LPA checked residents’ locked medications and observed a 30-day supply. LPA observed an adequate supply of PPE and cleaning supplies in the facility garage. Tour continued outside of the facility. LPA observed covered seating outside of the facility. At approximately 10:45AM, LPA observed 11 holes in the screen of the sliding glass door leading to a resident room.

Facility tour continued to the kitchen. LPA observed a 7 day supply of non-perishable items and a 2 day supply of perishable foods. Social distancing is maintained in the common and dining areas. Bathrooms toured. LPA observed hand-washing signs and trash cans with a lid. Bathrooms were equipped with liquid soap and paper towels. At approximately 10:50AM, LPA observed 8 small holes in the wall of the hallway bathroom. LPA observed Clorox wipes under the sink in the hallway bathroom and in the hallway cabinet. Tour continued to resident bedrooms. Beds in room 2 and room 3 were observed to be 3 feet apart with head to toe orientation. At approximately 10:55AM, LPA observed the window screen in room 3 to be bent, as well as 8 small holes in the wall. Beds in room 1 were observed to be 6 feet apart.

CONTINUED TO LIC809-C

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
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
VISIT DATE: 01/26/2022
NARRATIVE
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Staff records were reviewed for good health and infection control training. Facility staff was observed with mask on. Residents wear masks when away from the community. Resident's files do not have updated emergency contact information. Upon review of records, LPA observed that hospice was initiated for R1. Administrator was contacted via telephone, LPA confirmed that the Fresno CCL office was not notified of the hospice initiation for R1.

Based on observation and record review, deficiencies are being cited in accordance with the California Code of Regulations, Title 22, Division 6, Chapter 8.

Exit interview conducted. A Plan of Correction was reviewed and developed with Administrator via telephone. As a COVID-19 precautionary measure, a copy of this report will be provided via email and an electronic read receipt confirms receiving this document. Report signed on-site by facility representative.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: 01/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above when 2 bottoles of Clorox wipes were found to be accessible to 5 out of 5 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2022
Plan of Correction
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3
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Caregiver removed the Clorox wipes and locked them in a secure cabinet. POC CLEARED during inspection.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 01/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 01/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when 2 window screens were observed not in good reparit and multiple holes in the walls of the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2022
Plan of Correction
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Licensee agrees to have the window screens in the facility replaced and to fill/patch all the holes in the walls of the bathroom and resident rooms.
Type B
Section Cited
CCR
87632(d)(2)
d) If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver… which shall include, but not be limited to, the following requirements: (2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when Licensee did not notify the Department of the initiation of hospice care for 1 resident which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2022
Plan of Correction
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Licensee agreed to submit a written statement detailing the steps the facility will take to ensure the requirements of section 87632 Hospice Care Waiver are met.
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: 01/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4