Guardian Care And Rehabilitation Center
GUARDIAN CARE AND REHABILITATION CENTER in MANTECA, CA — inspection on August 29, 2025.
Found 14 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 8/28/25, at 11:19 AM, with the Director of Nursing (DON), the DON stated other staff members on shift of the day of the alleged abuse should have been interviewed.
The DON further stated other residents, in the care of CNA 8, should have been interviewed.
The DON explained the importance of interviewing staff on shift from the day of the alleged abuse and other residents was to ensure a complete investigation and to prevent further incidents.
The DON explained it was important to look at employee records to help in the investigation and to find out if there were similar complaints.A review of an undated facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, indicated, .All reports of resident abuse (including injuries of unknown origin) .are reported .and thoroughly investigated .The individual conducting the investigation as a minimum .interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .interviews the resident's roommate, family members, and visitors .interviews other residents to whom the accused employee provides care or services .reviews all events leading up to the alleged incident .
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Guardian Care and Rehabilitation Center
410 Eastwood Ave Manteca, CA 95336
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 8/26/25, at 2:16 PM, with Resident 102, Resident 102 stated she was not happy with the care she received while being turned by staff. Resident 102 explained there was only one nursing aide who turned her while providing care.
During a phone interview on 8/27/25, at 2:42 PM, with Certified Nursing Assistant (CNA) 3, CNA 3 confirmed that she had turned Resident 102 alone, without the assistance of another staff.
During a concurrent interview and record review on 08/28/25, at 10:55 AM, with the Director of Staff Development (DSD), the DSD confirmed that CNA 3 had turned Resident 102 alone, when there should have been two CNAs providing care.
The DSD stated it was important to follow Resident 102's care plan to ensure that the resident was receiving proper care, using the correct interventions, and to achieve goals for health conditions.
Review of an undated facility policy titled, Repositioning, indicated, .Repositioning the Resident in Bed 1.
Check the care plan…to determine resident’s specific positioning needs…and the number of staff required to complete the procedure .
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Guardian Care and Rehabilitation Center
410 Eastwood Ave Manteca, CA 95336
SUMMARY STATEMENT OF DEFICIENCIES
Federal health inspectors cited GUARDIAN CARE AND REHABILITATION CENTER in MANTECA, CA for a deficiency under regulatory tag F-F0658 during a standard health inspection conducted on 2025-08-29.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Ensure services provided by the nursing facility meet professional standards of quality.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of GUARDIAN CARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
Federal health inspectors cited GUARDIAN CARE AND REHABILITATION CENTER in MANTECA, CA for a deficiency under regulatory tag F-F0684 during a standard health inspection conducted on 2025-08-29.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of GUARDIAN CARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
Federal health inspectors cited GUARDIAN CARE AND REHABILITATION CENTER in MANTECA, CA for a deficiency under regulatory tag F-F0688 during a standard health inspection conducted on 2025-08-29.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of GUARDIAN CARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
Review of an undated facility policy titled, Safety and Supervision of Residents, the policy indicated, .Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Resident supervision is a core component of the systems approach to safety.risk factors and environmental hazards include the following: a.
Bed safety.falls.Review of an undated facility policy titled, Fall Risk Assessment, the policy indicated, .The staff will seek to identify factors that may contribute to falling .Review of an undated facility policy titled, Transportation, Diagnostic Services [medical tests, examinations, and procedures used to identify or diagnose a health condition], the policy indicated, .A member of the nursing staff, or social services, will accompany the resident to the diagnostic center when the resident's family is not available.
The nursing staff must always monitor and seat next to the residents .The nursing staff must check if residents are strapped in their seats, safe and secure.Review of the facility staff job descriptions titled, Certified Nursing Assistant, dated 2003, the document indicated, .Make resident comfortable.Assist in transporting residents to/from appointments.Assist with lifting, turning, moving, positioning, and transporting residents into and out of beds, chairs, bathtubs, wheelchairs, lifts etc.Ensure that residents who are unable to call for help are checked frequently.Assist with the application of slings, elastic bandages, binders, etc. [et cetera; and other similar things].Follow established safety precautions in the performance of all duties.
Facility ID:
Federal health inspectors cited GUARDIAN CARE AND REHABILITATION CENTER in MANTECA, CA for a deficiency under regulatory tag F-F0692 during a standard health inspection conducted on 2025-08-29.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide enough food/fluids to maintain a resident's health.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of GUARDIAN CARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
Federal health inspectors cited GUARDIAN CARE AND REHABILITATION CENTER in MANTECA, CA for a deficiency under regulatory tag F-F0740 during a standard health inspection conducted on 2025-08-29.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of GUARDIAN CARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
Federal health inspectors cited GUARDIAN CARE AND REHABILITATION CENTER in MANTECA, CA for a deficiency under regulatory tag F-F0755 during a standard health inspection conducted on 2025-08-29.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of GUARDIAN CARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
Federal health inspectors cited GUARDIAN CARE AND REHABILITATION CENTER in MANTECA, CA for a deficiency under regulatory tag F-F0757 during a standard health inspection conducted on 2025-08-29.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure each resident’s drug regimen must be free from unnecessary drugs.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of GUARDIAN CARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
Federal health inspectors cited GUARDIAN CARE AND REHABILITATION CENTER in MANTECA, CA for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-08-29.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of GUARDIAN CARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
Federal health inspectors cited GUARDIAN CARE AND REHABILITATION CENTER in MANTECA, CA for a deficiency under regulatory tag F-F0778 during a standard health inspection conducted on 2025-08-29.
Category: Administration Deficiencies
The facility was found deficient in the following area: Help the resident make transportation arrangements to and from radiology services.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of GUARDIAN CARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
Federal health inspectors cited GUARDIAN CARE AND REHABILITATION CENTER in MANTECA, CA for a deficiency under regulatory tag F-F0865 during a standard health inspection conducted on 2025-08-29.
Category: Administration Deficiencies
The facility was found deficient in the following area: Have a plan that describes the process for conducting QAPI and QAA activities.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of GUARDIAN CARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
Federal health inspectors cited GUARDIAN CARE AND REHABILITATION CENTER in MANTECA, CA for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-08-29.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of GUARDIAN CARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.