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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607987
Report Date: 05/16/2022
Date Signed: 05/17/2022 08:20:53 AM


Document Has Been Signed on 05/17/2022 08:20 AM - It Cannot Be Edited

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 ELDERLYFACILITY NUMBER:
197607987
ADMINISTRATOR:FLORINDA P. QUIZONFACILITY TYPE:
740
ADDRESS:15005 LA FONDA DRIVETELEPHONE:
(714) 228-9133
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY:6CENSUS: 4DATE:
05/16/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Administrator Eliza De Honor TIME COMPLETED:
12:40 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 Analysts (LPA's) Jose Villalobos, Ashley Calderon, and Valeria Maldonado conducted an unannounced visit with Administrator Eliza De Honor.

During todays visit LPA toured the physical plant and observed the following deficiency that are in need of correcting(See the attached LIC 809D)

California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.


Exit interview conducted. Appeal rights were discussed and provided to Eliza De Honor.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022
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 2


Document Has Been Signed on 05/17/2022 08:20 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/30/2022
Section Cited

1
2
3
4
5
6
7
87633 Hospice Care of Terminally Ill Residents(a) The licensee shall be permitted to accept or retain residents... in the facility and receive hospice services from a hospice agency in the facility when all of the following conditions are met:(1) The licensee has received a hospice care waiver from the department.
8
9
10
11
12
13
14
This was not met as evidenced by;

Facility has 3 hospice residents when the waiver only approves for up to 2. This poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2