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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275294362
Report Date: 12/14/2022
Date Signed: 12/19/2022 04:57:30 PM


Document Has Been Signed on 12/19/2022 04:57 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:SWANER GUEST HOMEFACILITY NUMBER:
275294362
ADMINISTRATOR:ROSARIO MAGSAMBOLFACILITY TYPE:
740
ADDRESS:18615 SWANER AVENUETELEPHONE:
(831) 449-9379
CITY:SALINASSTATE: CAZIP CODE:
93906
CAPACITY:6CENSUS: 5DATE:
12/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, Mathew MagsambolTIME COMPLETED:
02:00 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 Administrator, Mathew Magsambol, Continual Administrator's Certification expires 04/08/2024. 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 currently occupied by residents were clean. 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. First Aid kit is on site and complete.

LPA Hurt observed 3 of the 6 bedrooms to be cluttered, and not suitable for use as resident rooms.
LPA Hurt observed both facility bathrooms, and showers to be dirty. (shower heads not clean, old rusty shower rack hanging on the shower head, dirty bathroom organizers in both bathrooms.)
LPA Hurt observed the water temperature to be 128 degrees. LPA Hurt observed the facility to be very cold, and no thermostat to give room temperature.
LPA Hurt observed toxins and chemicals for cleaning in garage, backyard, and inside the facility unlocked and accessible to residents. LPA Hurt observed the facility refrigerator to have several containers not labeled or dated.
LPA Hurt observed several dogs in the backyard of the facility that are not being well cared for. LPA Hurt observed a dog barking, and growling aggressively inside a facility bedroom.

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 Administrator, Mathew Magasambol 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: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
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 12/19/2022 04:57 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: SWANER GUEST HOME
FACILITY NUMBER: 275294362

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2022
Section Cited

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87303 Maintenance and Operation
(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. The following requirement has not been met as evidenced by:
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Administrator will clean rooms, bathrooms including showers, and send proof to LPA by POC date 12/29/2022.
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LPA Hurt observed three of the six facility rooms to be very cluttered, and not suitable for residents, resident bathrooms including showers were not clean which poses an immediate, health, safety or personal rights risk to residents in care.
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Type B
12/29/2022
Section Cited

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GENERAL FOOD SERVICE REQUIREMENTS.
All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. The following requirement has not been met as evidenced by:
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Administrator will clean entire fridge and send proof to LPA by POC date 12/29/2022.
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During today's inspection LPA observed several food containers with no date, or label which poses a potential health, safety, or personal rights risk to residents in care.
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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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 12/19/2022 04:57 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: SWANER GUEST HOME
FACILITY NUMBER: 275294362

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(b)(1)
Maintenance and Operations (b) A comfortable temperature for residents shall be maintained at all times.(1) The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C). The following requirement has not been as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA observed the facility to be cold, and no thermostat to read temperature which poses a potential health, safety or personal rights risk to residents in care.
POC Due Date: 12/28/2022
Plan of Correction
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Licensee will install thermostat to show facility temperature, and ensure it is above 68 degrees and send proof to LPA by POC date of 12/28/2022.
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). The following requirement has not been met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA Hurt observed the facility resident bathroom in hallway water measured at 128 degrees which poses a potentiol health, safety or personal rights risk to residents in care.
POC Due Date: 12/15/2022
Plan of Correction
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Administrator will send proof water temperature is adjusted below 120 degrees and above 105 degrees by 12/18/2022 POC date.
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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4


Document Has Been Signed on 12/19/2022 04:57 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: SWANER GUEST HOME
FACILITY NUMBER: 275294362

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(7)(a)
Plan of operation 87208
(7) Sketches, showing dimensions, of the following:

(A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms to be used for nonambulatory residents and for bedridden residents, other than for a temporary illness or recovery from surgery as specified in Sections 87606(d) and (e)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation 3 of the 6 bedrooms labeled as resident room on facility sketch are being used for other purposes.
POC Due Date: 12/28/2022
Plan of Correction
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Administrator will submit updated facility sketch to licensing by 12/18/2022 POC date.
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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4