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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609479
Report Date: 10/27/2023
Date Signed: 10/27/2023 12:32:13 PM


Document Has Been Signed on 10/27/2023 12:32 PM - 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:TULLER RESIDENTIAL HOMEFACILITY NUMBER:
197609479
ADMINISTRATOR:CERVANTES, HILDAFACILITY TYPE:
740
ADDRESS:11174 CHARNOCK RDTELEPHONE:
(310) 995-8120
CITY:LOS ANGELESSTATE: CAZIP CODE:
90034
CAPACITY:4CENSUS: 1DATE:
10/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Hilda CervantesTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced visit using the CARE Inspection Tool. LPA met with Administrator Hilda Cervantes, and the purpose of today’s visit was explained. LPA was granted access into the facility. The facility is licensed to serve four (4) non-ambulatory residents ages 60 and over, of which one (1) may be bedridden. Facility has an approved hospice waiver for 2. Currently the facility has 1 resident.

The facility is a single-story home consisting of a kitchen, dining area, living room, two bedrooms, one bathroom, laundry area, and a patio with chairs. Facility has two (2) bedrooms and one (1) bathroom for resident use.

LPA conducted a records review of (1) resident records, (5) staff records. All client & staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (1) Client Medication Administration Records and did not observe any discrepancies at the time of visit.

LPA and Hilda Cervantes toured the inside and outside of the facility. Two client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space was observed. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathroom was found to be within Title 22 regulation. The water temperature properly measured between 105-120F (111.9 F). Smoke and carbon monoxide combo are in operable conditions. Fire extinguisher was fully charged and operable.

Continued on LIC 809-C

SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira GonzalezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
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


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: TULLER RESIDENTIAL HOME
FACILITY NUMBER: 197609479
VISIT DATE: 10/27/2023
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LPA observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. First aid kit was checked. Last facility disaster drill was conducted on: 10/01/2023.

LPA observed the facility's infection control practices.

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 report was provided to Administrator Hilda Cervantes.
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira GonzalezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC809 (FAS) - (06/04)
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