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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006000
Report Date: 09/13/2022
Date Signed: 09/13/2022 03:30:36 PM


Document Has Been Signed on 09/13/2022 03:30 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 HOME ON COMPASSFACILITY NUMBER:
306006000
ADMINISTRATOR:DO, KHANH KFACILITY TYPE:
740
ADDRESS:21302 COMPASS LNTELEPHONE:
(714) 679-2590
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY:6CENSUS: 3DATE:
09/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Caregiver Ali JohnsonTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted, granted entry into the facility by Staff and explained the reason for the visit.

During the visit LPA toured the facility with Caregivers. Facility is a 6 bedroom,( 5 resident bedrooms 1 staff bedroom) and 3 bathrooms single story home. There are 3 Residents in care. LPA observed residents relaxing in bedrooms watching TV. LPA observed proper covid signage at front entrance of facility as well as a sign in, sanitization and temperature check station. Facility has required Department postings. LPA observed copy of Administrators Certificate expiring 04/26/23 LPA observed Emergency Disaster plan posted. LPA toured all Residents rooms, all rooms had required furnishings. All restrooms observed contained soap, toilet paper , sanitizer and towels. Restrooms had operating wash basin and toilet. Facility has operating audible alarms for each sliding door entrance/exit. Facility has operating smoke detectors and carbon monoxide detectors. Facility has 2 fire extinguishers which are fully charged. Facility has supply of PPE. Facility has 2 refrigerators and 1 freezer with ample food supply. LPA observed facility has emergency food and water supply. Facility has a secured location for resident medication and files. Facility has 30 days supply of medications for Residents. LPA reviewed Residents files during visit. LPA reviewed 3 out of 3 files. Residents emergency contact information and Physicians reports are current. Facility has secure location for Sharps and toxins. Facility has several designated visitation areas.

No deficiencies noted during todays visit. An exit interview was conducted with Caregiver and a copy of report was left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022
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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