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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003529
Report Date: 09/19/2022
Date Signed: 09/19/2022 10:59:10 AM


Document Has Been Signed on 09/19/2022 10:59 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:GUARDIAN ANGELS HOMES IFACILITY NUMBER:
306003529
ADMINISTRATOR:SONIA GARCIAFACILITY TYPE:
740
ADDRESS:18021 E. SANTA CLARA AVENUETELEPHONE:
(714) 269-7307
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:6CENSUS: 5DATE:
09/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:Sonia P. GarciaTIME COMPLETED:
11:15 AM
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On 09/19/2022, Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced visit to Guardian Angels Homes I. The purpose of today's visit was to conduct a Required 1 Year focusing primarily on the Infection Control. At 9:21am, LPA Cho was greeted and allowed entry by Staff Roy Bueno after completing the Coronavirus 2019 (COVID-19) screening procedure. Staff Stephanie Magana was present at the facility, and Licensee/Administrator (Admin) Sonia Garcia arrived at the facility at 9:35am. As of today, there are no active COVID-19 cases in the facility. Facility screens and documents temperatures for visitors on a sign in sheet. LPA observed the required COVID-19 precautionary signs posted on the front door and throughout the facility. The Complaint Poster (PUB475) was within the size regulation. The facility is licensed for six non-ambulatory residents and has a hospice waiver for four. There are currently five residents living in the facility of which one is receiving hospice care. The Administrator's Certificate for Sonia P. Garcia expires on 06/29/23 and 03/01/24 for Kelly S. Francia.

At 9:24am, LPA Cho conducted a tour of the physical plant along with Admin Garcia. The single story home consists of six resident bedrooms and five resident bathrooms. There is one staff bedroom. The facility also has two living rooms, dining area, kitchen, and an attached two car garage with a laundry area. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew, and non-skid mats were in place. Resident bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. LPA observed hand washing signs in all bathrooms. LPA Cho tested the hot water temperature in the resident bathrooms and the temperature measured at 118.2 degrees Fahrenheit in the Bathroom #1, 116.0 degrees Fahrenheit in Bathroom #2, 119.6 degrees Fahrenheit in Bathroom #3, 117.6 degrees Fahrenheit in Bathroom #4, and 117.5 degrees Fahrenheit in Bathroom #5.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GUARDIAN ANGELS HOMES I
FACILITY NUMBER: 306003529
VISIT DATE: 09/19/2022
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LPA Cho inspected the kitchen along with Admin Garcia and Staffs Bueno and Magana. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was fully charged and serviced on 03/04/22. The smoke/carbon monoxide detectors and auditory devices were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the residents.

LPA Cho toured the outside grounds with the Admin. There were no bodies of water present. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards, and the exit gates were self-closing and self-latching. There were no security bars or weapons on the premises.



LPA Cho reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E). Facility has a plan for COVID-19 testing residents and staff as well as a plan for isolation as needed. Facility has back-up emergency food and water supply. The First Aid Kit met all the required components except a first aid manual, and the facility had sufficient PPEs. Facility has the infection control plan in place, and LPA discussed the Assembly Bill (AB) 665. This bill would require residential facilities serving adults, residential care facilities for persons with chronic life-threatening illness, and residential care facilities for the elderly with existing internet service to provide at least one internet access device that can support real-time interactive applications, is equipped with video conferencing technology, and is dedicated for client or resident use. The facility has an existing internet service and provides an iPad upon request.

LPA Cho reminded the importance of staying abreast with CCLD's COVID-19 guidance by reviewing and printing the Provider Information Notices (PINs) as well as by attending the CCLD Informational Calls. The PINs can be accessed at: www.ccld.ca.gov.

Based on the observations made during today's visit, no deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit. An exit interview was conducted with Licensee/Administrator Sonia Garcia, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022
LIC809 (FAS) - (06/04)
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