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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320086
Report Date: 09/27/2024
Date Signed: 09/27/2024 12:29:12 PM

Document Has Been Signed on 09/27/2024 12:29 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:GOLDEN TIARA VILLAFACILITY NUMBER:
198320086
ADMINISTRATOR/
DIRECTOR:		CADUNGOG, TIARAFACILITY TYPE:
740
ADDRESS:17223 ATKINSON AVENUETELEPHONE:
(310) 408-6228
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY: 6CENSUS: 5DATE:
09/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:32 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 09/27/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit using the CARE Inspection Tool. LPA met with Caregiver, Melita Jagmany, and the purpose of today’s visit was explained. We were later joined by Administrator, Arlene Feliciano. The facility is licensed to serve residents aged 60 and over. The facility is approved for six (6) non-ambulatory residents, of which 1 may be bedridden and a hospice waiver for four (4). There are currently five (5) residents living in the facility.
Physical Plant/Structure The facility is a single-story home in a residential neighborhood. It consists of three (3) bedrooms, two (2) bathrooms, living room, dining room, kitchen, office, storage room, front yard, back yard with a shaded patio, and detached garage. All walkways around the home were observed clean, clear, and free of debris, obstructions, and hazards. LPA did not observe any bodies of water on the premises.
Bedrooms LPA inspected the three (3) resident bedrooms and observed them to be clean and in good repair. All rooms were observed with the required furniture including beds, dressers, nightstands with lamps, and ample storage space for resident’s personal belongings. LPA observed the beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. LPA
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GOLDEN TIARA VILLA
FACILITY NUMBER: 198320086
VISIT DATE: 09/27/2024
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observed an ample supply of linens, blanket, and comforters in good repair stored in a closet in the hallway. All bedrooms were observed with ample lighting.
Bathrooms LPA inspected all bathrooms and observed them to be within Title 22 regulations and were clean and operational. All safety handrails were secured. LPA observed showers to have non-skid mats and a shower chair. LPA observed an ample supply of hygiene products, incontinent products, and towels. The water
temperature in the bathrooms measured 107.8-degrees and 107.4-degress Fahrenheit.
Kitchen LPA inspected the facility kitchen and found it to be clean and sanitary. LPA observed all appliances to be operational and in good repair. LPA observed a 3- day supply of perishable foods and a 7-day supply of non-perishable foods, properly packaged, stored, and labeled. LPA observed all knives and sharps to be secured in a locked cabinet under the kitchen sink. LPA observed all cleaning and laundry supplies secured in a locked cabinet in the kitchen. LPA observed an ample supply of cookware, dishware, and cutleries in good repair. The water temperature in the kitchen measured 107.6-degree Fahrenheit.
Common Rooms During the time of visit, LPA observed the facility to be appropriately furnished. The living room has recliners to accommodate all residents. LPA observed games, activities and reading material available for residents. The dining room has a large rectangle table with chairs to accommodate all residents. The facility was maintained at a comfortable temperature. LPA observed all walkways and hallways in the home to be clean, clear, and free of obstructions and hazards.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GOLDEN TIARA VILLA
FACILITY NUMBER: 198320086
VISIT DATE: 09/27/2024
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Files LPA reviewed the files for five (5) residents and found they contained the
required documents. LPA reviewed the files for five (5) staff and found they
contained the required documents, certification, and training. The Administrators Certificate is valid till 04/03/26. LPA observed all required posting posted throughout the facility. LPA received and reviewed a copy of the facility’s Liability insurance through Acord valid till 12/28/24. During facility file review LPA observed the facility’s Licensing Fees are current.
Medications LPA observed all Centrally Stored Medication secured in a locked cabinet in the kitchen and are inaccessible to residents. LPA reviewed the medications for five (5) residents and the Medication Administration Record (MAR) and the found the medications to be consistent with documentation. LPA observed all medication in their original packaging.
Infection Control LPA reviewed and observed the facility’s infection control plan posted on the wall. LPA observed sanitizing stations throughout the facility. LPA observed masks and gloves available. LPA observed staff wearing gloves while working with residents. LPA observed a 30-day supply of Personal Protective Equipment (PPE). LPA observed Infection Control signs posted throughout the facility.
Safety LPA observed the smoke and carbon monoxide detectors to be fully operational. LPA observed two fully charged fire extinguisher, one in the kitchen, and the other in the living room near the entrance, purchased on 02/20/24. The last emergency drill was conducted on 06/10/24. All exits are marked with an EXIT sign. LPA inspected the First Aid Kit and observed it to have the required items and
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GOLDEN TIARA VILLA
FACILITY NUMBER: 198320086
VISIT DATE: 09/27/2024
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a manual. The facility has a working telephone. LPA observed all emergency
phone numbers and Emergency Disaster Plan posted in the kitchen.

LPA did not observe or cite any deficiencies.

An exit interview was conducted with Administrator, Arlene Feliciano, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
LIC809 (FAS) - (06/04)
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