306005209-12-12-2022-22-AS-KSGH-CM2UZC-20221212150119

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005209
Report Date: 12/12/2022
Date Signed: 12/12/2022 03:01:29 PM

Document Has Been Signed on 12/12/2022 03:01 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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	GOLDEN TIARA GUEST HOME		FACILITY NUMBER:	306005209
ADMINISTRATOR:	GONZALES, DESIDERIO		FACILITY TYPE:	740
ADDRESS:	1776 S TIARA STREET		TELEPHONE:	(714) 317-4324
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92802
CAPACITY:	6	CENSUS: 4	DATE:	12/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Rhoda Ycasas, licensee Timothy Ycasas, licensee		TIME COMPLETED:	03:20 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	On 12/12/2022, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection. LPA was greeted and granted entry by Zenaida Berroya, caregiver after explaining the purpose of the visit and undergoing the COVID-19 screening process. Licensees Rhoda and Timothy Ycasas were notified of the visit by staff and arrived shortly afterwards to assist with the visit. At approximately 1:40pm, LPA accompanied by caregiver Danilo Berroya toured the physical plant of the facility. There are currently four (4) residents in care, one (1) of which is attending day program at the time of the visit. Residents are observed relaxing in their respective bedrooms or in the common areas. All appear clean and well taken care of. Bedrooms are all equipped with the required elements of furnishing. Physician orders for postural supports have been verified for all four residents. Bathrooms are equipped with grab bars and slip mats. An ample supply of linen is observed. Facility is observed to be clean, sanitary and free of odors in all areas inspected. Sharp instruments are kept secured in a kitchen drawer equipped with a functioning key lock. Cleaning supplies are securely stored under the kitchen sink as well as in cabinets in the laundry area. The centrally stored medication is located in a cabinet with a key lock that is observed to be functional. LPA observed a sufficient supply of food and water present. The fire extinguisher present is charged and has a maintenance tag shown to be current until December 2022. Staff members present are adequately cleared and associated in Guardian. Administrator certificates displayed are current. CONTINUED ON FORM LIC809-C

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GOLDEN TIARA GUEST HOME	FACILITY NUMBER: 306005209
	VISIT DATE: 12/12/2022

NARRATIVE

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CONTINUED FROM FORM LIC809

LPA and caregiver toured the outside of the facility. The sliding door in resident R1's bedroom is observed to have a non-functioning latch and is propped shut with a broom handle on the floor which was promptly removed by the caregiver. The decking on the left of this sliding door has rotted out, which leaves a hole with screws apparent. Several screens are shown to be ripped around the door handles.

LPA observes two sheds are used for storage. Outdoor furniture and a shaded area are present in the backyard. The perimeter gates on both sides of the house are self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.

The staff bedroom door is observed to be left open and unlocked by staff present. Medications, insecticide and cleaning supplies are observed in the room and are accessible to individuals in care.

Based on the observations made during today’s visit, two deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility representative and a copy of this report along with appeal rights was provided and left at facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/12/2022 03:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GOLDEN TIARA GUEST HOME	FACILITY NUMBER: 306005209
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

The California Code of Regulations Section 87303(a) regarding Maintenance and Operation indicates that: "The facility shall be clean, safe, sanitary and in good repair at all times." This requirement is not met as evidenced by: Licensing Program Analyst observed a sliding door latching mechanism to be non-functional, torn screens as well as a hole in the facility's surrounding wooden deck.
	Deficient Practice Statement
1 2 3 4	Based on observation conducted during the visit, the licensee did not comply with the section cited above in 3 instances which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/12/2023
	Plan of Correction
1 2 3 4	Licensee is to perform all necessary repairs to the deficiencies cited above before the Plan of Corrections due date.

Type B

Section Cited

CCR

87309(a)

The California Code of Regulations Section 87309(a) regarding Storage Space indicates that: "Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients." This requirement is not met as evidenced by: Licensing Program Analyst observed that the door accessing the staff bedroom was left both open and unlocked, leaving items such as medications and insecticide accessible to the individuals in care.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/12/2023
	Plan of Correction
1 2 3 4	Licensee to provide staff with in-service training on the necessity to maintain all dangerous items inaccessible, including in the staff bedroom. Documentation of the conducted training to be provided to the Department before the Plan of Correction due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

LIC809 (FAS) - (06/04)

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