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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320086
Report Date: 11/13/2022
Date Signed: 11/13/2022 05:49:17 PM

Document Has Been Signed on 11/13/2022 05:49 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:GOLDEN TIARA VILLAFACILITY NUMBER:
198320086
ADMINISTRATOR:CADUNGOG, TIARAFACILITY TYPE:
740
ADDRESS:17223 ATKINSON AVENUETELEPHONE:
(310) 408-6228
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY: 6CENSUS: 4DATE:
11/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Manuel BandolaTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced Annual required and infection control visit to the above facility. LPA was met by Arlene Feliciano; Administrator and the purpose of today’s visit was explained.

There are currently (4) residents in the facility. (4) residents are ambulatory, (4) are non-ambulatory, (0) bedridden. The facility is a single-story structure located in a residential neighborhood. It consists (3) bedrooms, (2) full bathrooms, shaded back yard, front yard, laundry room and attached 2 garage.

LPA and Arlene Feliciano toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1-3 are occupied by residents and contain the mandated furniture. The (2) bathrooms have grab bars and non-skid mats and are clean and operational. First aid kit is fully stocked with manual; smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. (1) Resident file along with medications are current. (1) Staff file is current. Ample supply of perishable and nonperishable food, hot water temperature is (117.3) degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, (2) fire extinguishers is fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Jeremiah Randle
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2022
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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Document Has Been Signed on 11/13/2022 05:49 PM - It Cannot Be Edited


Created By: Jeremiah Randle On 11/13/2022 at 05:07 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN TIARA VILLA
FACILITY NUMBER: 198320086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, interview, and record review, the licensee did not comply with the section cited above in [2] out of [2] (persons) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2022
Plan of Correction
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Administrator will associate or provide department with background clearence prior to scheduling uncleared individuals for work in the facility.
Type A
Section Cited
CCR
87355


This requirement is not met as evidenced by:
Deficient Practice Statement
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POC Due Date: 11/14/2022
Plan of Correction
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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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Jeremiah Randle
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2022


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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GOLDEN TIARA VILLA
FACILITY NUMBER: 198320086
VISIT DATE: 11/13/2022
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The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked, sanitizer/soap, paper towels, in all the bathrooms and additional sanitation supplies are stored in the garage. LPA observed staff and residents wearing masks, resident private rooms will be converted to isolation rooms (if needed) trash cans with lids, cart for PPE’s, mitigation plan posted and/or in folder, Fit testing completed for staff, and required postings throughout the facility. Visitor designated area, facility has internet & IPAD for residents to use, resident’s temperatures are checked and logged (once a day). Emergency contacts updated and posted; PPE's are enough for 30 days. All residents and staff are vaccinated and boosted. LPA observed 2 individuals working and not cleared or associated to the facility per Arlene Feliciano Administrator.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation and civil penalty see 809D

An exit interview was conducted with Arlene Feliciano Administrator, and a hard copy was provided, and Appeal Rights provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Jeremiah Randle
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2022
LIC809 (FAS) - (06/04)
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