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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881292
Report Date: 05/06/2022
Date Signed: 05/06/2022 10:52:22 AM

Document Has Been Signed on 05/06/2022 10:52 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 HOME CARE LLCFACILITY NUMBER:
331881292
ADMINISTRATOR:ROBINSON, BLAIR ALAYNEFACILITY TYPE:
735
ADDRESS:25365 THEDA STTELEPHONE:
(310) 908-7702
CITY:PERRISSTATE: CAZIP CODE:
92570
CAPACITY: 4CENSUS: 0DATE:
05/06/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Blair Robinson and Raye Robinson, LicenseesTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an announced pre-licensing inspection at the facility. The LPA met with Licensees, Blair Robinson and Raye Robinson. There are currently no clients in care.

Application: The application is for a new Adult Residential Facility (ARF). The fire clearance has been granted for four (4) ambulatory clients.

Buildings and Grounds: The home is composed of three (3) client bedrooms, one (1) staff room/office, two (2) sitting rooms, two (2) bathrooms, a laundry area, kitchen and dining areas (2), garage, and front/back yard areas. The interior/exterior walkways of the home were observed to be clutter free with no obstructions present. Smoke and Carbon Monoxide detectors were tested and operable. There are no pools or other bodies of water located at the home. According to Raye Robinson, there are no weapons stored in the home. Rooms, furniture, beds, mattresses appeared to be in good repair. The bedrooms are fully furnished, and privacy is available. The dining and living room areas are clutter free and in good condition. Outdoor areas had sufficient room for activities and leisure.

Storage and Supplies: Medications will be stored in a locked cabinet, inaccessible to any unauthorized individuals. Secured areas are available for facility files and client files. The first aid kit was observed to be available and complete. Linens, towels, and other equipment appeared to be in good repair and sufficient for the approved census. Fire extinguishers were available and fully charged.

Food Service: Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove are in working order. Sharps will be stored in a locked kitchen cabinet, available only to authorized individuals.

Forms: The following signs were observed to be posted at the home: Emergency Disaster Plan, Personal Rights, Facility Sketch (LIC 999), Complaint Poster, and Visitors Policy.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2022
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 HOME CARE LLC
FACILITY NUMBER: 331881292
VISIT DATE: 05/06/2022
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The following was observed to be needed:

- Washer and dryer machines need to be installed and observed to be in working order.
- Lock installed under cabinet for cleaning supplies and toxins.
- Leaking water heater at the back of the building
- Labor Law poster needs to be obtained
- Secure trailer stairs at the back of the property

The LPA will inform the Centralized Applications Bureau (CAB) the home is ready for licensure once follow ups are received. This report was discussed with and a copy provided to the Licensees.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
LIC809 (FAS) - (06/04)
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