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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881080
Report Date: 04/14/2022
Date Signed: 04/14/2022 02:48:50 PM

Document Has Been Signed on 04/14/2022 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GUARDIAN ANGELS ADULT RESIDENTIAL CAREFACILITY NUMBER:
331881080
ADMINISTRATOR:TUGGLE, DENESICAFACILITY TYPE:
735
ADDRESS:26038 HUXLEY DRIVETELEPHONE:
(562) 331-4525
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 4CENSUS: 0DATE:
04/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Licensee- Denesica TuggleTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA), Janira Arreola made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by Licensee, Denesica Tuggle, who was informed of the purpose of the visit. At the time of visit there was 1 staff and no clients present. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA made an advisory note on LIC9102TA for Licensee to post Covid-19 posters throughout the facility. Specifically in staff and resident restrooms, Licensee was advised to post hand washing signs. Additionally, a separate LIC9102TA was made advising licensee to post her administrator certificate at the facility.

The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer) in all restrooms. An advisory note was made on LIC 9102TA for licensee to stock paper towels in 1 out of 2 facility restrooms.

The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks. The Facility has isolation rooms designated for those who possess suspected and confirmed COVID symptoms. An advisory note was made on LIC 9102TA for trash bins with lids to be placed inside all 4 resident isolation rooms. Additional, and advisory note was made on a seperate LIC9102TA for the placement of hand sanitizers in all 4 resident rooms.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GUARDIAN ANGELS ADULT RESIDENTIAL CARE
FACILITY NUMBER: 331881080
VISIT DATE: 04/14/2022
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The facility also has a designated infection control lead and cleans and disinfects the highly touched surfaces during each shift, and as needed. LPA observed a sufficient amount of PPE supplies. An LIC9102TA was created advising Licensee to get N95 fit tested.

An exit interview was conducted and a copy of this report was reviewed and provided to facility licensee, Denesica Tuggle.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC809 (FAS) - (06/04)
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