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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002305
Report Date: 06/24/2024
Date Signed: 06/24/2024 03:59:09 PM

Document Has Been Signed on 06/24/2024 03:59 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/
DIRECTOR:		IRENE GARDEFACILITY TYPE:
735
ADDRESS:3728 BRIDGEFORD LANETELEPHONE:
(209) 569-0625
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 6CENSUS: 5DATE:
06/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Irene GardeTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 6/24/24 atv approximately 12:45 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual visit. LPA Jensen met with Administrator Irene Garde and explained the purpose of today's visit. The Administrator holds a current Administrator's certificate good through December of 2024. The inspection tool was used during the course of this visit.

LPA Jensen toured the exterior. All paths were clear of obstruction. The backyard has patio furniture and a shaded area for client use. LPA Jensen observed a variety of debris stacked against the facility exterior including but not limited to a discarded mattress, broken chair, a stack of LED light bulbs. LPA Jensen also observed numerous cigarette butts on dry grass which potentially creating a fire hazard. A window screen with a tear was observed and the self latching spring on the rear gate was inoperable. LPA Jensen toured the interior of the facility. The thermostat was set at 78 degrees which falls within the required range of 68-85 degrees Fahrenheit. The bathroom water temperature was measured at 105 degrees and is compliant. All required postings were observed on the walls displayed in prominent locations. There are night lights available in the hallway. All toxins. medications and knives were locked and inaccessible to residents in care. The first aid kit was observed to be complete and in compliance. The fire extinguisher was last serviced in May of 2024 and is in compliance. The smoke detector and carbon monoxide detector were observed to be in good working order. The emergency disaster plan was reviewed and is in compliance. LPA Jensen toured the kitchen. Cabinets were observed with loose hinges and the kitchen linoleum is starting to tear. There was a 2 day supply of perishable food and a 7 day supply of non-perishable food. There is an adequate supply of linens available. LPA Jensen observed stains on the carpeting in every room and insects at the fire exit door in client bedroom. LPA Jensen reviewed 2 of 2 staff files and 5 of 5 client files. The files were determined to be complete and in compliance. The liability insurance was reviewed and determined to be complete and compliant. Deficiencies are being cited pursuant to the California Code of Regulations (CCR). Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report and appeals rights were provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2024
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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Document Has Been Signed on 06/24/2024 03:59 PM - It Cannot Be Edited


Created By: Maja Jensen On 06/24/2024 at 03:31 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GARDE'S GUEST HOME
FACILITY NUMBER: 507002305

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Jensen's observation of debris in yard, window screen tear, broken gate spring, loose kitchen cabinets, stained carpet and worn linoleum, the licensee did not comply with the section cited above in 6 counts which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2024
Plan of Correction
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The Administrator will submit a plan with a timeline to the Department outlining how they will come in to compliance withthe above listed regulation.
Type B
Section Cited
CCR
80087(a)(1)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Jensen's observation of insects going under the carpeting in a client bedroom at the fire exit door which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2024
Plan of Correction
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The Licensee will schedule a pest control service to be completed by the POC due date and submit a receipt for service to teh Department.
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:Lisa Rios
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2024


LIC809 (FAS) - (06/04)
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