197609479-10-17-2022-11-AS-MLEN-CKAMQE-20221017094833

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609479
Report Date: 10/11/2022
Date Signed: 10/17/2022 09:48:51 AM

Document Has Been Signed on 10/17/2022 09:48 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	TULLER RESIDENTIAL HOME		FACILITY NUMBER:	197609479
ADMINISTRATOR:	CERVANTES, HILDA		FACILITY TYPE:	740
ADDRESS:	11174 CHARNOCK RD		TELEPHONE:	(310) 995-8120
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90034
CAPACITY:	4	CENSUS:	DATE:	10/11/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Hilda Cervantes-Administrator		TIME COMPLETED:	04:00 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) Mario Leon connducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Hilda Cervantes, Administrator, and the purpose of today’s visit was explained. The facility is licensed to serve 4 elderly with dementia (ages 60+).

Tuller Residential Home is an elderly residential facility licensed to serve a total of four (4) non-ambulatory residents. Tuller Residential is a single story home consisting of: kitchen, dining area, living room, two bedrooms, laundry area, patio with chairs. Fire Clearance is approved for three (3) non-ambulatory and one (1) bedridden in room # 1. Facility has two (2) bedrooms and one (1) bathroom for resident use. Licensee will have 24/7 awake staff, approved two hospice waivers.

LPA and administrator toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 108.1 F. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable.

A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable.
See 809-C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: TULLER RESIDENTIAL HOME	FACILITY NUMBER: 197609479
	VISIT DATE: 10/11/2022

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
26
27
28
29
30
31
32

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations ( Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there were no deficiencies observed. Technical assistance notes were provided regarding non-perishable food supply, please see LIC9102.

Exit interview held. A copy of the report was provided to Hilda Cervantes

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3