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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003532
Report Date: 07/01/2022
Date Signed: 07/01/2022 11:55:16 AM


Document Has Been Signed on 07/01/2022 11:55 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 IVFACILITY NUMBER:
306003532
ADMINISTRATOR:KELLY FRANCIAFACILITY TYPE:
740
ADDRESS:13541 TEA HOUSE STREETTELEPHONE:
(714) 812-0137
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:6CENSUS: 6DATE:
07/01/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Licensee Sonia GarciaTIME COMPLETED:
12:05 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) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff, and explained the reason for the visit. LPA Haley was temper checked and screened before entering. Facility staff called Licensee Sonia Garcia who arrived and was present for the visit. Administrator (AD) Kelly Francia arrived as the tour of the facility began and remained present for the remainder of the visit. AD Francia has a current administrators certificate that expires 3/1/24.

At 10:40 AM LPA Haley and Licensee Garcia began the tour. LPA observed all required posting at the entrance and through out the facility. There's a screening station set up near the facility entrance and screening instructions with a QR Code that can be scanned and the pre-screening process can be completed on a mobile device. There's a closet near the entrance of the facility with an emergency supply of PPE. Emergency food and water supply, and emergency bags for all the residents ready to go.

LPA Haley and Licensee Garcia toured resident rooms and bathrooms. All resident bedrooms were clean, very well organized, and had all necessary requirements. All bathrooms were clean and organized. Hot water temperatures measured between 105 degrees Fahrenheit and 108.6 degrees Fahrenheit.

The kitchen was clean and very well organized. All knives and sharp objects were locked in a drawer near the stove. All burners on the stove were operational. The facility has a two day supply of perishable food items and seven day supply of nonperishable food items.

The backyard was clean, organized, and free of clutter. Side exit gates were self closing and self latching. In the backyard, LPA Haley observed a shaded patio area with a table and chairs. LPA observed a storage and two storage bins used for storage.


Continued on LIC 809C Dated 7/1/22
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2022
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 2


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 IV
FACILITY NUMBER: 306003532
VISIT DATE: 07/01/2022
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
26
27
28
29
30
31
32
There were no bodies of water observed. Smoke and carbon monoxide detectors were tested and are operational. No deficiencies are being cited during todays visit. An exit interview conducted and a copy of the report was provided to the Licensee Garcia.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2