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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247203432
Report Date: 01/15/2025
Date Signed: 01/15/2025 02:22:57 PM

Document Has Been Signed on 01/15/2025 02:22 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/
DIRECTOR:		SILVEIRA, LIDIAFACILITY TYPE:
740
ADDRESS:194 CLIPPER COURTTELEPHONE:
(209) 605-5239
CITY:ATWATERSTATE: CAZIP CODE:
95301
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
01/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Facility staff, Terri LaceyTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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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 staff Facility staff, Terri Lacey Continual Administrator Certification for Licensee Lidia Silveira expired 10/04/2024. The Administrator Certification Bureau received application for renewal on 10/07/2024. There are currently 5 residents who reside at this home and there is 0 residents 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 and performs disaster drills as required. Water temperature was tested at 119 degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible.

The facility does have an Emergency Disaster plan but it is on the older version of the form. Facility staff present did not provide Infection Control Plan, or Plan of Operation. Staff 1 does not have Health Screening Report. Resident 1 does not have required Tuberculosis Screening.

The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA 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 staff, Terri Lacey, and copy of report left at facility
Brenda ChanTELEPHONE: (650) 266-8800
Sarah HurtTELEPHONE: 559-243-8080
DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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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Document Has Been Signed on 01/15/2025 02:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA


FACILITY NAME: GUARDIAN ANGEL HOME CARE II
FACILITY NUMBER: 247203432

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

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 in the facility does not have an Infection Control Plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2025
Plan of Correction
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Licensee will submit Infection Control Plan to LPA by 01/29/2025 POC date.
Section Cited
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
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.
Stephenie DoubTELEPHONE: (916) 263-2131
Sarah HurtTELEPHONE: (916) 879-2602

DATE: 01/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2025

LIC809 (FAS) - (06/04)
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