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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320086
Report Date: 09/18/2025
Date Signed: 09/18/2025 11:42:04 AM

Document Has Been Signed on 09/18/2025 11:42 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
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: 4DATE:
09/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Ricardo HuerbanaTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 09/18/25, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Annual Visit using the CARE Inspection Tool. LPA met with Staff, Ricardo Huerbana, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The facility is licensed to serve six (6) 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) residents. There are currently four (4) residents residing in the facility.

Physical Plant/Structure The facility is a single-story structure in a residential neighborhood. It consists of three (3) bedrooms, two (2) bathrooms, living room, dining room, sitting area, kitchen, storage room, front yard, back yard with a shaded patio, and detached garage. All walkways around the facility 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 residents’ personal belongings. LPA observed the beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. LPA observed an ample supply of linens, blankets, 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 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 105.8- degrees and 105.5- degress Fahrenheit.

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2025
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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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: 09/18/2025
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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 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 cutlery in good repair. The water temperature in the kitchen measured 106.6- degree Fahrenheit.

Common Rooms During the time of visit, LPA observed the facility to be appropriately furnished. The living room has recliners and a couch to accommodate all residents. The sitting area has a couch and lounger. LPA observed games, activities, puzzles, and reading material available for residents. The dining room has a large table with chairs to accommodate all residents. LPA observed a screened fireplace inaccessible to 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. LPA observed all rooms and walkways have ample lighting.

Files LPA reviewed the files for four (4) residents and found they contained the required documents. LPA reviewed the administrator and two (2) staff files and found they contain the required documents, certification, and training. The administrator’s Administrator Certificate, number 7005359740, 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 that is valid till 12/18/2025. 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. Medications were observed in their original packaging. LPA reviewed the medications for four (4) residents and the Medication Administration Record (MAR) and found the medications to be consistent with properly documented records.

Safety LPA observed the smoke and carbon monoxide detectors to be fully operational. LPA observed two fully charged fire extinguishers, one in the kitchen, and the other in the living room near the entrance, purchased on 04/21/25. The last emergency drill was conducted on 06/21/25. All exits are marked with an EXIT sign. LPA inspected the First Aid Kit and observed it has the required items and a current manual. The facility has a working landline telephone. LPA observed all emergency phone numbers and Emergency Disaster Plan posted in the kitchen. There are no firearms or ammunition stored on the premises.

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GOLDEN TIARA VILLA
FACILITY NUMBER: 198320086
VISIT DATE: 09/18/2025
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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.

LPA did not observe or cite any deficiencies.

An exit interview was conducted with Staff, Ricardo Huerbana, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
LIC809 (FAS) - (06/04)
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