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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005209
Report Date: 12/20/2024
Date Signed: 12/20/2024 09:44:48 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/20/2024 09:44 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GOLDEN TIARA GUEST HOMEFACILITY NUMBER:
306005209
ADMINISTRATOR/
DIRECTOR:		GONZALES, DESIDERIOFACILITY TYPE:
740
ADDRESS:1776 S TIARA STREETTELEPHONE:
(714) 317-4324
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
12/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:14 AM
MET WITH:Caregiver - Emma VisonTIME VISIT/
INSPECTION COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility for the purpose of conducting an unannounced Required 1 Year Inspection. LPA was greeted and granted entry. LPA contacted Administrator Desiderio Gonzales via phone call. AD stated the clients moved out of the facility in July 2024. The facility is currently in the process of a change of location. The annual licensing fee is not due until December 23, 2024 per the Licensing Information System.

The facility is a single level structure with six bedrooms. LPA toured the interior and exterior portions of the facility and confirmed no clients in care. The home is occupied by friends of the Administrator.

For this visit, the facility was observed to be in compliance with Title 22 Division 6 of the California Code of Regulations.

LPA Mason conducted an exit interview with AD and Caregiver Emma Vison, and a copy of this report was provided during .
Armando J LuceroTELEPHONE: (949) 430-1222
Dwayne L MasonTELEPHONE: () -
DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
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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