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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006644
Report Date: 12/31/2024
Date Signed: 12/31/2024 11:59:25 AM

Document Has Been Signed on 12/31/2024 11:59 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GOLDEN TIARA GUEST HOMEFACILITY NUMBER:
306006644
ADMINISTRATOR/
DIRECTOR:		YCASAS, TIMOTHYFACILITY TYPE:
740
ADDRESS:2014 W SAINT ANNE PLACETELEPHONE:
(714) 733-8074
CITY:SANTA ANASTATE: CAZIP CODE:
92704
CAPACITY: 6CENSUS: 0DATE:
12/31/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Desiderio Gonzalez TIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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On 12/31/2024 Licensing Program Analyst (LPA) William Vanegas made an announced visit for the purposes of a pre-licensing visit. Upon arrival LPA Vanegas was greeted and granted entry to the facility by licensee (LIC) Desiderio Gonzalez. LPA Vanegas set up equipment and began tour of the facility at 8:19 AM and observed the following.

This is a one storied home with five bedrooms, two of which are staff rooms. and two bathrooms one of which is a staff bathroom and an attached two car garage. LPA Vanegas observed facility kitchen to be clean and sanitary. LPA Vanegas observed electric stove, microwave, and dishwasher to be operational. LPA Vanegas observed food pantry to hold a two day supply of perishable food and a seven day supply of non-perishable food.

LPA Vanegas observed facility to have operational smoke and carbon monoxide detectors in each room and in common areas. LPA Vanegas observed fire extinguishers to be fully charged and brand new with receipt attached to it. LPA Vanegas observed resident bedrooms to have all required furnishings such as a lamp, chair, chest drawer, bed, and required closet space. Linens were observed to be clean and in good repair meaning no strains or tears. All windows were observed to be screened in resident rooms and common areas.

LPA Vanegas observed resident bathrooms to be clean and free of debris and mildew. Bathrooms had all required furnishings such as hand rails, and slip resistant matts. Water temperature tested between 115.4 and 115.7 degrees. Toilet and faucet tested operational.

LPA Vanegas toured the outside of the facility and observed the following, LPA Vanegas observed a body of water that is fenced and locked with a fence that is 5ft high.
CONTINUED ON LIC809C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE: DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/31/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GOLDEN TIARA GUEST HOME
FACILITY NUMBER: 306006644
VISIT DATE: 12/31/2024
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LPA Vanegas observed there to be no obstructions on ramps or inclines, and no obstructions on emergency exit route. Side gates are self latching and not locked. LPA Vanegas observed a washer and dryer in the facility garage and it was tested to be operational.

LPA Vanegas conducted component III with Licensee and administrator and advised that email will be sent to application analyst and the next steps in the licensing process will be taken care of by the Centralized Application Bureau (CAB). An exit interview was completed and a copy of this report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024
LIC809 (FAS) - (06/04)
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