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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004794
Report Date: 02/23/2022
Date Signed: 02/23/2022 01:05:29 PM

Document Has Been Signed on 02/23/2022 01:05 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 SENIOR HOMES ON MADISONFACILITY NUMBER:
306004794
ADMINISTRATOR:KHANH DOFACILITY TYPE:
740
ADDRESS:3080 MADISON AVENUETELEPHONE:
(800) 707-4939
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 4DATE:
02/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Kaizan Mateo - CaregiverTIME COMPLETED:
01:20 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) Patricia Velazquez conducted an unannounced visit to Guardian Senior Homes on Madison. The purpose of today's visit was to conduct a Required 1 Year inspection. LPA Velazquez was allowed entry into the facility and met with Caregiver Kaizan Mateo. Caregiver Rena Gallardo was also present. Administrator Khanh Do arrived later during the visit. The facility is licensed for 6 non-ambulatory residents. The facility also has an approved hospice waiver for 4 residents. There are currently 4 residents living in the facility. The last emergency disaster drill was conducted on March 15, 2021. LPA Velazquez informed Caregiver Mateo that the facility annual fees were not current as of February 16, 2022. LPA also provided Caregiver with a copy of the Facility Transaction History that included a PIN to facilitate online payment of fees. Caregiver Mateo provided LPA Velazquez with proof of online payment of annual fees with Confirmation Code 965877.

At 11:33 AM LPA Velazquez conducted a tour of the physical plant along with Caregiver Mateo. The 2 story home consists of 7 resident bedrooms with 3 bathrooms downstairs and upstairs there is 1 staff bedroom with 2 staff bathrooms. The facility also has a living room, dining room, activity area, and kitchen. The 4 residents in the facility appeared well-groomed and well cared-for. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. LPA Velazquez observed bed rails on two of the resident beds. LPA was informed that the 2 residents were receiving hospice services. LPA was informed one vacant resident room was going to be painted tomorrow. Resident bath towels and personal hygiene supplies were adequately stocked. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew and a non-skid surface or mat was in place. LPA Velazquez tested the hot water temperature in the resident bathrooms and the temperature measured at 108.6 degrees Fahrenheit in the first bathroom and at 110.8 degrees Fahrenheit in the second bathroom and at 108.6 degrees Fahrenheit in the third bathroom.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2022
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 SENIOR HOMES ON MADISON
FACILITY NUMBER: 306004794
VISIT DATE: 02/23/2022
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
 LPA Velazquez inspected the kitchen along with Caregiver Mateo. Perishable and non-perishable food supply was checked and adequately stocked at the time of the visit. The fire extinguishers were fully charged. The smoke and carbon monoxide detectors are hardwired were tested and found to be operational. Toxins, sharps, and medications were locked and inaccessible to residents. First Aid kit was checked and was missing tweezers which Caregiver Mateo indicated he would obtain. The facility did have a First Aid manual which was outdated and LPA Velazquez advised Caregiver Mateo to obtain an updated First Aid manual.

LPA Velazquez along with Caregiver Mateo toured the outside grounds and no bodies of water were observed. There was shading and sufficient seating for residents. LPA and Caregiver observed the avocado tree in the back yard was overgrown and Caregiver indicated the tree was scheduled to be trimmed and will provide LPA with proof of such. Walkways around the home were clear of hazards and the exit gates were operational. The auditory alarms were noted to be in operating condition. There were no security bars or weapons on the premises. LPA Velazquez and Caregiver Mateo tested the signal system and noted that one call button was not in operating condition.

No resident or staff files were reviewed during this inspection. LPA Velazquez informed Caregiver Mateo to ensure a written physician's order for bed rails indicating the need is present in a resident's file pursuant to Title 22 Regulation Section 87608 Postural Supports.



There were no deficiencies issued during this Required 1 Year inspection. An exit interview was conducted with Administrator Khanh Do and Caregiver Kaizan Mateo and a copy of this report along with the 9102s were provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2