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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004794
Report Date: 03/04/2024
Date Signed: 03/04/2024 02:48:21 PM


Document Has Been Signed on 03/04/2024 02:48 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: 6DATE:
03/04/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:12 PM
MET WITH:Jo MatteoTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced Plan of Correction (POC) visit to follow up on deficiencies cited on 02/15/2024. LPA was greeted and granted entry into the facility and explained the reason for the visit.

Deficiency cited under Title 22 Regulation 87705(f)(1) pertaining to Care of Persons with Dementia has been cleared. Upon arrival to the facility, LPA observed sharps are secured. Licensee has complied with the POC.

Deficiency cited under Health and Safety code 1569.695(c) pertaining to Emergency Disaster Drills has been cleared. Facility conducted an emergency drill on 02/17/2024. Licensee has complied with the POC.

Deficiency cited under Title 22 Regulation 87412(c) pertaining to Personnel Records has been cleared. Licensee provided proof of training. Licensee has complied with the POC.

Licensee has complied with the advisory note dated 02/15/2024:
  • Licensee has obtained written physician orders for bed rails
  • Licensee has obtained updated physician report.







Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2024
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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