<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003531
Report Date: 09/23/2024
Date Signed: 09/23/2024 12:44:35 PM


Document Has Been Signed on 09/23/2024 12:44 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:GUARDIAN ANGELS HOMES IIIFACILITY NUMBER:
306003531
ADMINISTRATOR:SONIA GARCIAFACILITY TYPE:
740
ADDRESS:18351 E. SANTA CLARA AVE.TELEPHONE:
(714) 269-7307
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:6CENSUS: 6DATE:
09/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Sonia Garcia, Jonathan Harlan, Kelly FranciaTIME COMPLETED:
12:38 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. Facility is a one story home with 6 bedrooms, 1 staff room, 4 bathrooms, living room, family rooms, kitchen, dining room and a two car garage. The garage is kept locked and used for storage. Facility is licensed for 6 non-ambulatory residents and a hospice waiver for 4. LPA met with Administrator Jonathan Harlan and explained the reason for the visit. LPA and Administrator toured the facility. LPA observed the See Something, Say Something poster (PUB 475) posted in the main entry way of the facility. LPA observed fireplace in the living room is screened. LPA observed the fire extinguisher in the kitchen is fully charged. LPA observed a 2 day perishable and 7 day non-perishable food supply on hand in the kitchen. Knives and sharp objects are kept locked in a kitchen drawer. Cleaning supplies are kept locked under the kitchen sink. Medication is kept locked in a cabinet. LPA inspected the first aid kit, the first aid kit has all the required elements. LPA observed the facility has a tablet that connects to the internet for reside use. LPA inspected the 4 facility bathrooms. All 4 bathrooms are clean and operational. Hot water measured 112.0 to 112.6 degrees Fahrenheit. Smoke detector/carbon monoxide detectors tested operational. LPA toured all 6 resident rooms. All resident rooms had the required furnishings and bedding. LPA observed clean linens stored in the pantry of bathroom number 1. LPA toured the garage. The garage is kept locked and used for storage. LPA observed emergency food and water stored in the garage along with extra food and supplies. LPA toured the backyard. Both exit gates are operational. No bodies of water observed. There is a covered patio with a table and chairs. No obstacles or hazards observed in the backyard. LPA reviewed 3 staff files. No discrepancies observed. All staff present were associated to the facility. LPA reviewed 5 resident files and medication. No discrepancies observed. No obstacles or hazards observed inside of the facility. No deficiencies observed during the visit. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1