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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003532
Report Date: 09/24/2024
Date Signed: 09/24/2024 04:33:35 PM


Document Has Been Signed on 09/24/2024 04:33 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 IVFACILITY NUMBER:
306003532
ADMINISTRATOR:KELLY FRANCIAFACILITY TYPE:
740
ADDRESS:13541 TEA HOUSE STREETTELEPHONE:
(714) 812-0137
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:6CENSUS: 5DATE:
09/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Sonia GarciaTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator/Licensee Sonia Garcia and explained the reason for the visit. The facility is a single story home with 7 bedrooms (1 bedrooms is for staff), 5 bathrooms, living room, dining room, kitchen, laundry room, family room and a detached two car garage with an attached pool house in the backyard. There are two sheds in the backyard. Both sheds are used for tool storage. The facility has no pool. Facility is licensed for 6 non-ambulatory residents with a hospice waiver for 4. 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 the kitchen is clean and organized. Knives are kept locked in a kitchen drawer. Cleaning supplies are kept locked under the kitchen sink. LPA observed a two day perishable and a seven day non-perishable food supply on hand in the kitchen. The fire extinguisher in the kitchen is fully charged. LPA observed the medication is kept locked in the kitchen cabinet. The last emergency drill was conducted on September 10, 2024. Smoke detectors/carbon monoxide detectors tested operational. LPA observed all 6 resident rooms have the required furnishings and linens. LPA observed all 5 bathrooms are clean and operational. Hot water measured 107.0 to 107.8 degrees Fahrenheit. LPA and Administrator toured the backyard. LPA observed the family room sliding glass door does not have sliding screen door. LPA observed the garage is kept locked and stores extra furniture. The attached pool house is one room and has a kitchen/living area, a closet and a bathroom. The pool house and garage are kept locked and inaccessible to residents. The Administrator reported that the pool house and garage are not for resident use. LPA observed a shaded patio with chairs for residents to sit outside. No bodies of water observed. Both sheds are used for storage and do not have any hazardous items. No hazards observed in the backyard. Both exit gates on each side of the house are operational. LPA reviewed 3 staff files, no discrepancies observed. All 3 staff were present in the facility and background cleared and associated to the facility. LPA reviewed 6 resident files and medications, no discrepancies observed. No deficiencies are being cited as a result of the 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: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
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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