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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202805
Report Date: 01/23/2024
Date Signed: 01/23/2024 09:01:50 PM


Document Has Been Signed on 01/23/2024 09:01 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:SWANER GUEST HOME IIFACILITY NUMBER:
275202805
ADMINISTRATOR:MAGSAMBOL, MATTHEWFACILITY TYPE:
740
ADDRESS:978 ESTRADA COURTTELEPHONE:
(831) 449-9379
CITY:SALINASSTATE: CAZIP CODE:
93907
CAPACITY:6CENSUS: 5DATE:
01/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator, Mathew MagsambolTIME COMPLETED:
04:45 PM
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Licensing Program Analysts (LPA's) Sarah Hurt and Lisa Salazar conducted an unannounced visit today for the facility’s annual inspection. LPA met with Administrator Mathew Magsambol Continual Administrator's Certification expires April 08, 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. Licensee does not have Licensing Complaint poster (PUB 475) visible inside facility. Licensee does not have device solely for purpose of residents accessing internet. The facilities Emergency Disaster plan does not have marked outline on sketch for meeting place during emergencies or disasters. Licensee did not have current Admission Agreements in resident files. LPA Hurt observed food items in the refrigerator not in Tupperware with no labels or dates.

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 Administrator Mathew Magsambol, 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: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024
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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