331881080-3-10-2023-18-AS-CNWE-CPSRAU-20230310115144

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881080
Report Date: 03/10/2023
Date Signed: 03/10/2023 11:51:56 AM

Document Has Been Signed on 03/10/2023 11:51 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	GUARDIAN ANGELS ADULT RESIDENTIAL CARE		FACILITY NUMBER:	331881080
ADMINISTRATOR:	TUGGLE, DENESICA		FACILITY TYPE:	735
ADDRESS:	26038 HUXLEY DRIVE		TELEPHONE:	(562) 331-4525
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92555
CAPACITY: 4		CENSUS: 3	DATE:	03/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Denesica Tuggle, Licensee		TIME COMPLETED:	11:56 AM

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On March 10, 2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA Nwogene was greeted and granted entry by Caregiver, Evan Calvin Jr who was informed of the purpose of visit. Evan called Licensee, Denesica Tuggle who arrived at the facility shortly after. At the time of visit there was 1 staff and 1 residents present. LPA toured the facility inside and out with Evan.

Tour included:

Kitchen; LPA toured the kitchen and observed Kitchen area to be clean. LPA observed food is stored in a safe and healthful manner and fridge fully stocked with food.

Dining and Livingroom; LPA toured the dinning and Livingroom area. LPA observed area to be clean and furnitures in good condition. Temperature was 68 degrees Fahrenheit.

Hallway and Laundry room; LPA toured the hallway and observed hallway to be clean with no pathway obstruction. LPA inspected the fire extinguisher and found it to be in compliance and record to be up to date. Carbon monoxide & smoke detector were tested and functioning properly. LPA toured the laundry room and observed room to be clean. There were additional linens and towels in the cabinet.

Office and Medications; LPA toured the office and observed office to be clean. LPA observed medications were labeled and stored in separate bins inside of a locked medication cabinet in the office. Medications are distributed according to physician orders. The first aid kit was complete.

Bathroom; LPA toured two #2 hall bathroom and observed bathroom to be clean and equipped with grab bar. There is also a good number of personal toiletries available for the residents in care. The hot water measured at 119 degrees Fahrenheit

Continue on LIC809-C

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

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: 03/10/2023

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Continued from LIC809

Bedroom; LPA toured four #4 out of #4 residents bedroom and observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs and lighting. Night lights were maintained throughout the facility.

Garage; LPA tour the garage and observed garage to be clean and not cluttered.

Backyard; LPA toured the backyard and observed backyard to be clean and furnitures in good condition. The backyard was free from obstruction and the side gates remain unlocked. No bodies of water were observed.

Food Services: There are seven days non-perishable and two days of perishable food supply present, and all food was properly stored and available to residents.

Records: All staff present have a criminal record clearance in file and are confirmed as being associated with the facility. Five #5 staff and three #3 residents' records were reviewed. All required postings, including COVID’s postings, were posted in the Livingroom and throughout the facility. The administrator certificate expires on 9/11/2023

Interview; LPA interviewed one #1 staff and one #1 resident present. LPA was informed that the other two residents were at the day program.

No deficiencies noted at the time of visit. An exit interview was conducted, and a copy of this report was reviewed with and provided to Denesica Tuggle.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

LIC809 (FAS) - (06/04)

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