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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247203432
Report Date: 01/30/2024
Date Signed: 01/30/2024 07:51:43 PM


Document Has Been Signed on 01/30/2024 07:51 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
FRESNO ASC, 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:
01/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Facility Caregiver Maria BeltranTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Facility Caregiver Maria Beltran, Continual Administrator's Certification expires for Lidia Silveira 10/04/2024. There are currently 5 residents who reside at this home and there is 1 resident on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector. Water temperature was tested at 106 degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. The facility does have a current Emergency disaster plan, and conducts disaster drills as required.

There were no deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Facility Caregiver Maria Beltran, and copy of report left at facility
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
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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