306003529-11-6-2023-22-AS-CGUZ-CXBSK8-20231106125620

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003529
Report Date: 11/06/2023
Date Signed: 11/06/2023 12:56:30 PM

Document Has Been Signed on 11/06/2023 12:56 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	GUARDIAN ANGELS HOMES I		FACILITY NUMBER:	306003529
ADMINISTRATOR:	SONIA GARCIA		FACILITY TYPE:	740
ADDRESS:	18021 E. SANTA CLARA AVENUE		TELEPHONE:	(714) 269-7307
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92705
CAPACITY:	6	CENSUS: 5	DATE:	11/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Sonia Garcia Kelly Francia		TIME COMPLETED:	01:10 PM

NARRATIVE

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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Staff Roy Bueno. LPA discussed the purpose of the inspection and Administrator (AD) Sonia Garcia and Kelly Francia were contacted by phone and arrived at 9:46 a.m.

During the inspection LPA and ADs conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:

This is a one-story home with six resident bedrooms, five bathrooms, and one staff bedroom, two living room areas, one dining area, one lounge room and attached three car garage. The lounge room is currently being used as a staff bedroom and contains a bunk bed; a deficiency was cited on this date. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. The back yard has a shaded sitting area. LPA observed two staff and five resident present. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 109.7-115.5 F degrees. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged. Appliances were all inspected. Sharps were observed locked in a kitchen drawer. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents. Medication cabinet was observed to be locked. LPA reviewed five resident files and four staff files. LPA interviewed staff and residents present.

Based on the observations made during today’s inspection, two deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was left at the facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

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 11/06/2023 12:56 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GUARDIAN ANGELS HOMES I	FACILITY NUMBER: 306003529
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as a lounge room is currently being used as a staff bedroom which poses a potential safety risk to persons in care.
	POC Due Date: 12/06/2023
	Plan of Correction
1 2 3 4	AD stated the room would be vacated by staff and used soley as approved by fire clearance. LPA to make an additional visit to facility to verify plan of corretion.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, AD admission, and record review, the licensee did not comply with the section cited above as disaster drills are not being conducted which poses a potential safety risk to persons in care.
	POC Due Date: 12/06/2023
	Plan of Correction
1 2 3 4	AD stated they would begin conducting disaster drills quarterly and documenting on a disaster drill log. AD will provide LPA with a copy of most recent disaster drill by 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: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC809 (FAS) - (06/04)

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