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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603476
Report Date: 06/19/2023
Date Signed: 06/21/2023 08:52:15 AM


Document Has Been Signed on 06/21/2023 08:52 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:
198603476
ADMINISTRATOR:DE HONOR, ELIZAFACILITY TYPE:
740
ADDRESS:15005 LA FONDA DR.TELEPHONE:
(714) 342-8236
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY:6CENSUS: 5DATE:
06/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Administrator Eliza De Honor TIME COMPLETED:
04:10 PM
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Licensing Program Analysts (LPA's) Jose Villalobos conducted an unannounced Annual inspection focused on domains within the Compliance and Regulatory Enforcement (Care) Tools. LPA met with Administrator Eliza De Honor and the purpose of the visit was discussed.

Structure/Physical Plant:
The facility is part of a single story home located in a residential area and contains the following: living room, dining room, kitchen with refrigerator, oven, stove, dishwasher, sink/faucet, (4) resident rooms, (1) live in staff room (2) bathrooms for residents and (1) bathroom for the live in staff; bathrooms with shower, toilet and washbasin. A back yard with shaded area and seating for resident use. A connected garage inaccessible to residents for storage and Laundry; with washer and dryer. The residence is equipped with central air and heating. Adequate accommodations observed throughout facility. Facility observed to be clean of obstruction and debris. Bedrooms #1-#4 for resident use are equipped with: overhead lighting, chair, night stand, lamp in addition to overhead lighting, large drawer, beds for each resident, and closet space. Bathrooms have a working toilet, wash basin, shower, grab bars and nonskid mats. Medications are stored, locked and inaccessible to residents in care. Required linen/supplies observed. Facility has a working phone landline. There are (2) cordless phone for residents use. Fire Extinguisher 1 and 2 fully charged and up to date. The hot water temperature in the two bathrooms was measured within title 22 regulations. The food supply in the kitchen and pantry has at least two days perishable and seven days non perishable food. Smoke detectors and also carbon monoxide detectors observed, all detectors tested and operational. (2) Fire extinguishers observed and up to date. All appliances observed operational. Toxins and sharps observed to be Locked/stored for staff use only. POSTINGS: All necessary postings were observed to be posted in appropriate places. A current Plan of Operations and Disaster plan is maintained at the facility. RECORD REVIEW: LPA reviewed five (5) resident files, five (5) residents medications, and three (3) staff files.

Inspection tool completed and no deficiencies cited on todays visit. Exit interview conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2023
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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