<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198202004
Report Date: 07/01/2024
Date Signed: 07/01/2024 02:11:02 PM


Document Has Been Signed on 07/01/2024 02:11 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:ANGELS HOME CAREFACILITY NUMBER:
198202004
ADMINISTRATOR:ANA GUTIEREZ LECHUGAFACILITY TYPE:
740
ADDRESS:28030 ACANA RDTELEPHONE:
(310) 265-4994
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90274
CAPACITY:6; 6CENSUS: 4DATE:
07/01/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Vicenta MendozaTIME COMPLETED:
02:30 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
On 07/01/24 LPA Elvira Gonzalez conducted a case management. LPA arrived to this facility to conduct an investigation regarding complaint Control #11-AS-20240624135821. At 11:25 AM LPA Gonzalez and Licensee Vicenta Mendoza conducted a tour of the facility. While touring the outside grounds, LPA observed a piece of the fence in the backyard was in disrepair and missing.

Deficiencies were cited, please see LIC809-D.

An interview was conducted, and a copy of this report was provided to Licensee, Vicenta Mendoza.
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira GonzalezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 07/01/2024 02:11 PM - It Cannot Be Edited

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: ANGELS HOME CARE
FACILITY NUMBER: 198202004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/15/2024
Section Cited
CCR
87303(a)

1
2
3
4
5
6
7
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will repair the fence and submit photo proof to LPA Gonzalez via email to: Elvira.Gonzalez@dss.ca.gov by the POC due date.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above due to LPA observing a piece of the fence in the backyard in disrepair and missing, while touring the outside grounds, which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 CifuentesTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira GonzalezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2