Guardian Senior Homes on Madison

Type of visit: Required - 1 Year

On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for six non-ambulatory residents. Facility has an approved hospice waiver for six residents and the home currently has five residents, with two residents on hospice. Staff provided updated liability insurance that expires on 1/04/2027. LPA along with staff toured the facility at 9:10 AM. LPA toured the physical plant, checked food service, and facility documentation. The home consists of six resident bedrooms, living room, dining room, one staff room, kitchen, three bathrooms and an attached garage on the first floor. The second floor consists of one bedroom and one bathroom that is rented to a tenant. No residents reside on the second floor. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. At 9:35 AM, LPA observed a bottle of nail polish remover in a unsecured drawer in the bathroom closest to the entrance. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 110.6 degrees F and 116.7 degrees F in all bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Auditory exit alarms were operational during today's visit. LPA toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. LPA reviewed the infection control and emergency disaster plans. Facility conducts quarterly emergency drills with the last drill conducted on 1/19/2026. Outside grounds were toured. Walkways around the home were clear of hazards. There is shaded outdoor seating for residents. Exit gates are unlocked and operational. LPA observed the emergency food and water supply. First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of exercise. LPA reviewed five resident files and four staff files. Resident files contained documentation including admission agreements, physician reports, and resident appraisals. Two out of five resident files did not include evidence of TB testing. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPA reviewed medication storage and administration. Medications are stored in a locked closet. Medications are being administered per physician order. Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.the state’s words, verbatim · CDSS document, Feb 12, 2026

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Fred Arias made an unannounced case management visit and met with care giver Joe Mateo. The purpose of today’s visit was to follow up on incident report received by the Department on April 15, 2025, reporting the death of resident 1 (R1). Per death report received, R1 passed away on April 14, 2025, after being observed unresponsive on the floor next to their commode in their bedroom at approximately 3:38am. The facility performed CPR, called 9-1-1 and notified family and R1's physician. Time of death was declared at 3:50am by responding paramedics. During today’s visit LPA toured the interior of the facility and reviewed R1's file. LPA did not observe any immediate health and safety concerns during today’s visit. No deficiencies cited at this time. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 16, 2025

Type of visit: POC

Licensing Program Analyst (LPA) Fred Arias made an unannounced visit for the purpose of conducting a Plan of Corrections Inspection for a deficiency issued on 02/05/2025 during the required annual inspection. LPA was greeted and granted entry by staff Joe Mateo . LPA discussed the purpose of the inspection with staff. LPA toured the facility to check the deficiency has been corrected with staff Mateo. LPA observed no cameras on the second floor. Based on LPA's observation on today's visit, the Plan of Corrections has been fulfilled by the assigned POC due date of 02/19/2025, thus clearing the Type B deficiency CCR 87468.1(a)(2). An exit interview was conducted with staff Mateo and a copy of this report was provided to the facility representative.the state’s words, verbatim · CDSS document, Mar 11, 2025

Type of visit: Required - 1 Year

On this day Licensing Program Analyst (LPA) Fred Arias and Licensing Program Manager (LPM) Alisa Ortiz made an unannounced visit to conduct a required annual visit. LPA and LPM were greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents. Facility has an approved hospice waiver for 4 residents and the home currently has 4 residents, with 2 residents on hospice. Administrator (AD) Khanh Do has a valid certificate that expires on April 26, 2025. LPA along with staff Kaizan Mateo toured the facility at 8:30 AM. LPAs toured the physical plant, checked food service, facility documentation and the first aid kit. The home consists of 6 resident bedrooms, living room, dining room, and kitchen as well as 3 bathrooms and 1 staff room and 1 rented room upstairs. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 108.1 degrees F and 112.6 degrees F in all bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Auditory exit alarms were operational during today's visit. LPA toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts quarterly emergency drills with the last drill conducted on 12/15/2024. Outside grounds were toured. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. First aid kit contained all required items including tweezers, scissors and thermometer. There is shaded outdoor seating for residents. Exit gates are unlocked and unlatched. LPA observed cameras with audio on the second floor. LPA observed the emergency food supply. LPA reviewed four resident files and four staff files. All resident files contained required documentation including admission agreements, physician reports, resident appraisals, and physician orders for bed rails as indicated. Continued on LIC809-C dated 2/5/2025. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPAs reviewed medication storage and administration. Medications are stored in a locked closet. Some PRN medications were not available for 3 out of 4 residents. Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.the state’s words, verbatim · CDSS document, Feb 5, 2025

The state marks this report as 9 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Resident wandered away from the facility due to lack of care or supervision from staff.

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced initial 10-Day complaint visit to initiate the investigation into the above allegation and to deliver the findings of the investigation. LPA was greeted and granted entry into the facility and met with Caregiver Kaizan Mateo. LPA explained the reason for the visit. This agency has investigated the complaint alleging that resident wandered away from the facility due to lack of care and supervision. Regarding the allegation, the following was revealed: Two of two individuals interviewed denied the allegation. During the course of the interviews with the Reporting Party (RP), the RP confirmed that Resident 1 (R1) does not reside at 3080 Madison Ave Costa Mesa, CA 92626. During the initial visit on August 5, 2024 LPA reviewed documents including the Register of Facility Clients/Residents dated February 10, 2024. Per Register of Facility Clients/Residents R1 is not a resident at Guardian Senior Homes on Madison. CONTINUED ON LIC9099-C... Unfounded Therefore, the allegation is deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. LPA Ramirez conducted an exit interview with caregiver Mateo, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Aug 5, 2024 · control 22-AS-20240729141428

Type of visit: POC

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced Plan of Correction (POC) visit to follow up on deficiencies cited on 02/15/2024. LPA was greeted and granted entry into the facility and explained the reason for the visit. Deficiency cited under Title 22 Regulation 87705(f)(1) pertaining to Care of Persons with Dementia has been cleared. Upon arrival to the facility, LPA observed sharps are secured. Licensee has complied with the POC. Deficiency cited under Health and Safety code 1569.695(c) pertaining to Emergency Disaster Drills has been cleared. Facility conducted an emergency drill on 02/17/2024. Licensee has complied with the POC. Deficiency cited under Title 22 Regulation 87412(c) pertaining to Personnel Records has been cleared. Licensee provided proof of training. Licensee has complied with the POC. Licensee has complied with the advisory note dated 02/15/2024: Licensee has obtained written physician orders for bed rails Licensee has obtained updated physician report. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 4, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to Guardian Senior Homes on Madison. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the home and met with Caregiver Kai Mateo. Facility is licensed for 6 non-ambulatory residents, with a hospice waiver for 4. Facility has 6 residents during today's visit with 1 on hospice. Khan Do has an Administrator Certificate expiring on 04/26/2025. LPA Lyman along with Caregiver Kai Mateo toured the facility at 9:16 AM. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of seven resident bedrooms, three resident bathrooms, one staff room, living room, dining room, and kitchen. Second story houses a tenant and no residents. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 109.2 and 111.6 degrees F in all facility bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. During today's visit, auditory door alarms are operational. LPA observed a locked storage area for cleaning supplies under the kitchen sink. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. At 9:30 AM, LPA observed unsecured medications and sharps in the kitchen. Smoke detectors and Carbon Monoxide detectors are hardwired and tested operational during today's visit. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and observed ample shaded seating for residents. Exit gates are unsecured and operational. LPA observed residents relaxing in the facility and all appeared clean and well taken care of. Facility provides activities in the form of exercise and music therapy. CONTINUED ON LIC 809C DATED 2/15/2024. LPA observed emergency food and water supply. LPA reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility provided documentation of last fire drill conducted on 02/17/2023. At 10:15 AM, LPA reviewed six resident files and two staff files. Resident files contained required documents including admission agreements, physician reports and resident appraisals. Staff files reviewed contained required health screen/TB, and criminal record clearance. One out of two staff files do not have documented required training hours. At 11:05 AM, LPA reviewed medication storage and administration. Medications are stored in a locked cabinet and are audited monthly by staff. Medications are being administered per physician order. Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.the state’s words, verbatim · CDSS document, Feb 15, 2024