197607987-8-4-2022-28-AS-CWOG-CGXN54-20220803100854

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607987
Report Date: 08/03/2022
Date Signed: 08/04/2022 08:13:42 AM

Document Has Been Signed on 08/04/2022 08:13 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 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: 2	DATE:	08/03/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Diane Ragudo		TIME COMPLETED:	10:30 AM

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) Christine Wong conducted an unannounced annual required visit. LPA met with caregiver Diane Ragudo and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed resident and staff files. The facility is a single story house and located in a residential neighborhood area. The facility includes: kitchen, living room, dining area, four residents bedrooms, two bathrooms, one live in staff room and a attached garage. All 4 resident bedrooms were toured. Bedroom#1 and #3 have two beds, two chairs, drawers, required bed linen, furniture and sufficient lighting and closet space. Bedroom#2 and #4 have one bed, one chair, drawer, required bed linen, furniture and sufficient lighting and closet space. All two bathrooms were toured and they were clean, sanitary and in a good working condition. All bathrooms have required grab bars and non-skid mats. The hot water temperature in both two bathrooms were tested between 115.5 and 120 degrees which is within Title 22 regulation. The refrigerator in the kitchen and garage and kitchen cabinet have sufficient food supply for two days perishable and seven days non-perishable. All the sharp knives and utensils are locked in the kitchen cabinet and inaccessible to residents. All the appliances are clean and working properly. The common area such as living room and dining area are clean and have the required furniture. The front and back yard are maintained well and and the back yard has a shaded area with tables and chairs for residents to utilize. LPA also inspected the smoke detectors and carbon monoxide detectors and they are all interconnected and working well. LPA reviewed 2 resident files to confirm emergency contact is updated. LPA also reviewed two staff files to confirm health screenings and fingerprint clearances and they are all fingerprint cleared and have updated health screening in the personnel file. LPA also reviewed two residents medication and they are all centrally stored and they are all seemed accurate and updated.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022

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: 08/03/2022

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Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, disinfecting products are available in each residents' rooms and common area and facility is disinfected every time visitor used or residents used and facility will also have a deep clean for the facility each morning and night. The bathrooms have sufficient soap, paper towels, and signs, and PPE supplies are sufficient for more than 30 days.

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 Caregiver Diane Ragudo

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022

LIC809 (FAS) - (06/04)

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