198320086-12-5-2023-11-AS-EGOZ-CY8UDB-20231205142916

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320086
Report Date: 12/05/2023
Date Signed: 12/05/2023 02:29:23 PM

Document Has Been Signed on 12/05/2023 02:29 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:	GOLDEN TIARA VILLA		FACILITY NUMBER:	198320086
ADMINISTRATOR:	CADUNGOG, TIARA		FACILITY TYPE:	740
ADDRESS:	17223 ATKINSON AVENUE		TELEPHONE:	(310) 408-6228
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90504
CAPACITY:	6	CENSUS: 5	DATE:	12/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:02 AM
MET WITH:	Arlene Feliciano		TIME COMPLETED:	02:35 PM

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On 12/5/23 Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with caregiver Florencia Dupit, and the purpose of today’s visit was explained. LPA was granted access to the facility. Administrator Arlene Feliciano later joined LPA for this visit. The facility is licensed to operate for six (6) non-ambulatory age 60 and over, of which one (1) may be bedridden. Bedridden in any bedroom. Facility has a hospice waiver for four (4). Currently, there are five (5) residents in placement.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: two (2) client bedrooms, one (1) staff bedroom, two (2) bathrooms, living room, dining room, kitchen and an office.

LPA and caregiver Florencia Dupit toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in adequate condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. The bathrooms were found to be within Title 22 regulation. Water temperature properly measured at 106.2 F in bathroom 1 and 106.7 F in bathroom 2. LPA observed a comfortable temperature was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Two fire extinguishers were fully charged, smoke detectors and carbon monoxide were operable. A review of Medication Administration Records was maintained in order and accurate.

Continued on LIC 809-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN TIARA VILLA	FACILITY NUMBER: 198320086
	VISIT DATE: 12/05/2023

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The facility has a landline telephone on-site in working condition. Toxins and sharps were locked and inaccessible to clients. Medications were centrally stored and properly locked. First aid kit was checked an in order with manual. Outside grounds were toured and no bodies of water were observed. Patio furniture with umbrella was accessible. Exits and walkways around the home were free of debris and hazards.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved CCLD Mitigation Plan.

No deficiencies were cited at the time of this visit.

An exit interview was conducted, and a copy of this report along with appeal rights was provided to Administrator Arlene Feliciano.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

LIC809 (FAS) - (06/04)

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