507002305-7-25-2023-27-AS-CYAG-CU3KVD-20230725081411

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507002305
Report Date: 07/24/2023
Date Signed: 07/25/2023 08:14:32 AM

Document Has Been Signed on 07/25/2023 08:14 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	GARDE'S GUEST HOME		FACILITY NUMBER:	507002305
ADMINISTRATOR:	IRENE GARDE		FACILITY TYPE:	735
ADDRESS:	3728 BRIDGEFORD LANE		TELEPHONE:	(209) 569-0625
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY: 6		CENSUS: 4	DATE:	07/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Irene Garde		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Unannounced annual licensing visit made out to this facility on 07/24/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Irene Garde, who was briefly interviewed. It was learned that the facility designated Administrator, Irene Garde, and her husband, Leo Garde, were live-in caregivers as well. Current census was 4 residents. Tour of this facility was conducted. Kitchen area was toured. Cabinets and drawers were reviewed. Drawers and cabinets housing cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Drawers containing knives and other cutlery were observed to be locked and made inaccessible to the residents at this time. Food supply was reviewed for 2-day perishable and 7-day nonperishable food quantities at this time. Additional nonperishable food items were observed to be stored in the garage area. Dining room, living area, and all other areas designated for resident use were observed to be maintained and observed to be in compliance at this time. A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be present and maintained in compliance at this time. A tour of the resident restrooms was conducted. Shower areas, toilets, and wash basins were reviewed and observed to be functional and in good repair at this time. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees. Medication for resident use, located in dining area cabinet, was reviewed. Policies and procedures for dispensing, handling, and overall documentation of the resident medications were discussed with the facility designated Administrator at this time. Fire extinguishers (2) were observed to be placed in the kitchen area and laundry area and were annually inspected on 05/11/2023 from the local fire extinguisher company, Jorgensen Co, and in compliance at this

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GARDE'S GUEST HOME	FACILITY NUMBER: 507002305
	VISIT DATE: 07/24/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

time.
First aid kit was observed to be present and contained all of the required components at this time.
Linen closet, located in facility hallway, was observed to contain a sufficient supply of blankets, sheets, and towels for resident use.
Laundry area, located in adjacent to garage area, was observed to be made available to the residents at this time for those who were capable of doing so. Laundry detergents, bleach, and all other cleaning supplies were observed to be stored elsewhere where they were locked and made inaccessible to the residents at this time.
Exterior grounds of this facility was toured. Facility perimeter fence, side gates, and emergency exits were reviewed.
Additional garage space was reviewed and observed to be contain materials and items intended for upkeep and maintenance of this facility.

The following forms were requested to be updated and submitted into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 07/25/2023 08:14 AM - It Cannot Be Edited

Created By: Charlie Yang On 07/24/2023 at 12:14 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GARDE'S GUEST HOME	FACILITY NUMBER: 507002305
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

85076(d)(1)

Food Service

(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above since this facility did not have the adequate 7-days supply of nonperishable food items at all times which posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/25/2023
	Plan of Correction
1 2 3 4	The facility representative stated that additional non perishable food items will be purchased to make sure that there are 7-days worth available to the residents at all times. A statement of correction, along with a copy of the additional non perishable food items purchased, will be completed and submitted into CCL for review by this LPA by the due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Liza King

LICENSING EVALUATOR NAME:

Charlie Yang

LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3