<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002305
Report Date: 02/21/2024
Date Signed: 02/21/2024 12:07:43 PM

Document Has Been Signed on 02/21/2024 12:07 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GARDE'S GUEST HOMEFACILITY NUMBER:
507002305
ADMINISTRATOR:IRENE GARDEFACILITY TYPE:
735
ADDRESS:3728 BRIDGEFORD LANETELEPHONE:
(209) 569-0625
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 6CENSUS: 5DATE:
02/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Irene GardeTIME COMPLETED:
12:15 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
On 2/21/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management for incident reports received for occurrences on 12/11/23 and 12/12/23. LPA Jensen with Licensee Irene Garde and explained the purpose of today's visit.

On 12/11/23 Resident 1 (R1) left the facility and did not return. A police report was filed for missing persons. On 12/12/23 R1 was located and brought back to the facility. Also on 12/12/23 law enforcement arrived at facility and took R1 in to custody due to an outstanding warrant. R1 has not returned to the facility to date. The facility has is not holding a bed for the resident at this time and they have not received updates regarding the resident's whereabouts.

During the course of the visit LPA Jensen reviewed facility records including the facility sign out log, house rules, admission agreement, care provider notes for R1, physician's report, needs and service plan, pre-placement appraisal. An interview was also conducted with Administrator/Licensee Irene Garde. Based on an interview conducted with the Licensee, residents either use the sign out log or give a verbal notification when leaving the facility. LPA Jensen observed the sign out log to have multiple entries made by R1 that had no date indicated. Technical assistance was provided.

LPA Jensen also inspected the food supply during the course of the visit. LPA Jensen observed in excess of 2 days of perishable food and 7 days of non-perishable food.

No deficiencies were observed. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2024
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 1