197609479-10-15-2025-11-AS-QHUH-DMGRA7-20251015125041

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609479
Report Date: 10/15/2025
Date Signed: 10/15/2025 12:51:05 PM

Document Has Been Signed on 10/15/2025 12:51 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	TULLER RESIDENTIAL HOME		FACILITY NUMBER:	197609479
ADMINISTRATOR/ DIRECTOR:	CERVANTES, HILDA		FACILITY TYPE:	740
ADDRESS:	11174 CHARNOCK RD		TELEPHONE:	(310) 995-8120
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90034
CAPACITY: 4		CENSUS: 2	DATE:	10/15/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:53 AM
MET WITH:	Hilda Cervantes - Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:00 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	Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit. The LPA arrived at 9:53AM and met with the Administrator Hilda Cervantes and explained the reason for the visit. Entrance interview conducted. Beginning at 10:02AM, the LPA and the Administrator toured the physical plant areas inside and outside to ensure there were no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There was a fireplace in the living room, which was observed to be screened and inaccessible. The facility’s hallways had two (2) closets: one (1) closet stored extra linens and locked facility files, and one (1) closet was secured and led to the facility’s attic. The facility maintained a comfortable temperature throughout the visit. Required postings were observed on the entryway walls. KITCHEN: Knives, medications, and cleaning supplies were stored inaccessible. Kitchen appliances were clean and in operable condition. The facility had a sufficient supply of perishable and non-perishable food. Emergency food and water were sufficient and stored in the kitchen. Food in the refrigerator and freezer were observed to be properly stored with labels and dates in addition to an extra freezer. Laundry machines were observed attached to the kitchen area and were operational. Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 10/15/2025 12:51 PM - It Cannot Be Edited

Created By: Quoc Huynh On 10/15/2025 at 12:32 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: TULLER RESIDENTIAL HOME	FACILITY NUMBER: 197609479
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Type B

Section Cited

CCR

87468.2(a)(1)

(a) In addition to the rights listed in Section 87468.1 ... residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations ... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 2 out of 2 resident bedrooms had video surveillance which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/15/2025
	Plan of Correction
1 2 3 4	The Licensee removed the cameras during the visit. POC Cleared.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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

	Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:

	Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025

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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: TULLER RESIDENTIAL HOME	FACILITY NUMBER: 197609479
	VISIT DATE: 10/15/2025

NARRATIVE

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BEDROOMS/RESTROOMS: There were two (2) total bedrooms, both private and had direct exits to the outside. Bedroom #1 was approved for one (1) bedridden resident. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The LPA observed cameras in the resident bedrooms that were installed by the Licensee. The Administrator stated they utilize the cameras to supervise the residents and do not have an audio component. The facility’s camera policy was disclosed in the admission agreement; however, use of cameras in private areas is a violation of residents’ personal rights. The Administrator contacted the Licensee who removed the cameras during the visit. The facility plans to submit an exception/waiver request to the Regional Office to re-install the cameras. There was one (1) total restroom in the facility which was shared. The restroom was clean and sanitary and in operating condition with grab bars and non-slip surfaces. The restroom was sufficiently stocked with soap and paper products. Hot water was tested and measured at 115.7 degrees F, which is within the required range.

OUTDOOR AREA: The outdoor area consisted of one (1) shared courtyard with the subsequent facility operated by the Licensee. It was observed to have patio furniture in good condition with shade. There were two (2) side gates: one (1) contained facility storage and garbage bins, and one (1) side gate is used for emergencies and had a self-latching mechanism. No bodies of water noted, and exits were free of obstructions.

RECORDS: Record review began at 10:20AM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025

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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: TULLER RESIDENTIAL HOME	FACILITY NUMBER: 197609479
	VISIT DATE: 10/15/2025

NARRATIVE

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INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and reviewed annually as required. Emergency disaster drills are conducted quarterly, with the last documented drill on 07/13/2025. One (1) fire extinguisher was observed in the kitchen and was recently serviced on 09/11/2025. Smoke and carbon monoxide detectors were tested at 11:09AM and were operational at the time of the visit.

MEDICATIONS: Medication review began at 11:15AM. Medications were centrally stored and kept inaccessible. Medications were observed for two (2) residents. Medications were labeled and checked for expiration dates. Medications were properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to LIC 809-D).

Exit interview conducted. A copy of today's report and Appeal Rights were reviewed and provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025

LIC809 (FAS) - (06/04)

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