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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004794
Report Date: 02/15/2024
Date Signed: 02/15/2024 11:56:12 AM


Document Has Been Signed on 02/15/2024 11:56 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 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: 6DATE:
02/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Kai MateoTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to Guardian Senior Homes on Madison. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the home and met with Caregiver Kai Mateo. Facility is licensed for 6 non-ambulatory residents, with a hospice waiver for 4. Facility has 6 residents during today's visit with 1 on hospice. Khan Do has an Administrator Certificate expiring on 04/26/2025.

LPA Lyman along with Caregiver Kai Mateo toured the facility at 9:16 AM. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of seven resident bedrooms, three resident bathrooms, one staff room, living room, dining room, and kitchen. Second story houses a tenant and no residents. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 109.2 and 111.6 degrees F in all facility bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. During today's visit, auditory door alarms are operational. LPA observed a locked storage area for cleaning supplies under the kitchen sink. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. At 9:30 AM, LPA observed unsecured medications and sharps in the kitchen. Smoke detectors and Carbon Monoxide detectors are hardwired and tested operational during today's visit. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and observed ample shaded seating for residents. Exit gates are unsecured and operational. LPA observed residents relaxing in the facility and all appeared clean and well taken care of. Facility provides activities in the form of exercise and music therapy. CONTINUED ON LIC 809C DATED 2/15/2024.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
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 4


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: 02/15/2024
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LPA observed emergency food and water supply. LPA reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility provided documentation of last fire drill conducted on 02/17/2023. At 10:15 AM, LPA reviewed six resident files and two staff files. Resident files contained required documents including admission agreements, physician reports and resident appraisals. Staff files reviewed contained required health screen/TB, and criminal record clearance. One out of two staff files do not have documented required training hours. At 11:05 AM, LPA reviewed medication storage and administration. Medications are stored in a locked cabinet and are audited monthly by staff. Medications are being administered per physician order.




Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/15/2024 11:56 AM - 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 SENIOR HOMES ON MADISON
FACILITY NUMBER: 306004794

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed unsecured sharps and medications in kitchen. This poses an immediate health and safety risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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2
3
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Licensee to secure noted items and forward proof to LPA by POC due date. Staff secured items during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 02/15/2024 11:56 AM - 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 SENIOR HOMES ON MADISON
FACILITY NUMBER: 306004794

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on record review, the licensee did not comply with the section cited above. The last emergency drill was conducted on 02/17/2023. This poses a potential health, and safety risk to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
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Licensee to conduct an emergency drill for quarter 1 and forward proof to LPA by POC due date.
Type B
Section Cited
CCR
87412(c)
Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on record review, the licensee did not comply with the section cited above in one out of two staff. Staff 2 does not have required annual training which poses a potential health and safety risk to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
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Licensee to ensure all staff are current on training and forward proof to LPA by POC due 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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4