197607987-8-11-2021-28-AS-JVIS-C5SW3S-20210811165624

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607987
Report Date: 08/11/2021
Date Signed: 08/11/2021 04:57:28 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	LA MIRADA VILLA FOR THE ELDERLY		FACILITY NUMBER:	197607987
ADMINISTRATOR:	FLORINDA P. QUIZON		FACILITY TYPE:	740
ADDRESS:	15005 LA FONDA DRIVE		TELEPHONE:	(714) 228-9133
CITY:	LA MIRADA	STATE: CA	ZIP CODE:	90638
CAPACITY:	6	CENSUS: 3	DATE:	08/11/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Administrator Eliza De Honor		TIME COMPLETED:	01:30 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	Licensing Program Analyst/ (LPA) Jose Villalobos conducted an unannounced annual inspection visit focused on Domain for Infection Control at the La Mirada Villa for the Elderly Facility. LPA was allowed entry into the facility by staff, Administrator Eliza De Honor arrived shortly after. The purpose of the visit was discussed. The facility is licensed for six (6) residents of which (5) may be non-ambulatory, (1) may be bedridden, and is approved for up to (2) hospice care residents. Currently, there are (2) non-ambulatory residents and (1) Bedridden resident residing in the facility, all are over the age of 60, with (1) resident in hospice care. LPA was screened upon entry into the facility per guidelines. As part of the inspection, LPA Villalobos reviewed: (3) resident files, (3) resident medication records, (3) staff files and inspected the inside facility and outside grounds. The facilities’ last fire drill was conducted on 8/1/2021. Required postings were observed throughout the facility. The one story house located in a residential neighborhood consists of (5) bedrooms (1) used for live in staff, (2) resident bathrooms, living room, dining room, Family/ Den room, kitchen, attached garage with laundry area and storage, patio cover with sufficient seating. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A 2- day supply perishable and 7-day supply of non-perishable foods are present in the facility. LPA observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA observed the following during inspection of residents rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers. Bathrooms fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA observed bathrooms water temperatures were found to be within Title 22 regulation. Continued on LIC 809-C

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LA MIRADA VILLA FOR THE ELDERLY	FACILITY NUMBER: 197607987
	VISIT DATE: 08/11/2021

NARRATIVE

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Facility Carbon Monoxide and Smoke Detectors were tested and working properly. The facility has (1) Fire Extinguisher was checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to residents. Medications are centrally stored and in a locked storage cabinet. Facility first aid kit is fully stocked with manual was checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to residents. Infection Control Domain was concluded.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted and a copy of the Facility Evaluation Report was provided to Eliza De Honor.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021

LIC809 (FAS) - (06/04)

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