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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198203250
Report Date: 07/07/2025
Date Signed: 07/07/2025 01:54:39 PM

Document Has Been Signed on 07/07/2025 01:54 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SALVATION ARMY ALEGRIA, THEFACILITY NUMBER:
198203250
ADMINISTRATOR/
DIRECTOR:		XOCHITL SANTAMARIAFACILITY TYPE:
736
ADDRESS:2737 SUNSET BLVDTELEPHONE:
(323) 454-4200
CITY:LOS ANGELESSTATE: CAZIP CODE:
90026
CAPACITY: 50CENSUS: 16DATE:
07/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:59 AM
MET WITH:Ana Aguirre, DirectorTIME VISIT/
INSPECTION COMPLETED:
01:16 PM
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced visit for an Annual Inspection. Upon arrival, LPA met with Ana Aguirre (Director) who assisted with the visit. The purpose of the visit was explained upon arrival. The facility is licensed to serve licensed to serve a total of fifty (50) chronically Ill ambulatory and non-ambulatory, adults ages 18-59, children may be present as part of a family unit.

This is a 3-story facility in Los Angeles, CA. consists of: first floor: staff offices; staff lobby, staff break room, multipurpose room, conference room, industrial kitchen, dining area, 3 common restrooms. Second and third floor: 16 client apartments, medication room, Two (2) laundry rooms, storage rooms, Administrator Office, and common restrooms. One washer stopped working this weekend and the facility has scheduled service to repair the washing machine. The facility has three (3) other washing machines that clients may use.
The facility has a sprinkle fire system throughout. Outdoor shaded playground was observed.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. The facility has sufficient PPE supplies and has an Infection Control Plan.
Physical Plant & Environment Safety: There are 16 Client Apartments that have their own bedroom, kitchen, bathroom and living room. All client units/apartments had the required furniture for comfort and safety and had sufficient lighting. All outdoor passages were free of obstruction. Bathrooms were clean, toilets and water faucets worked properly. Water temperature was measured at 126.5 -130.1 units were outside of the required range of 105-120 Degrees F. Client bath towels, toiletries and personal hygiene supplies were adequately available. All storage areas for cleaning solutions, toxins, knives, and hazardous items are locked in the facility storage rooms. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguishers were observed to be fully charged.

(Continued on 809(C)

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2025
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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Document Has Been Signed on 07/07/2025 01:54 PM - It Cannot Be Edited


Created By: Alberto Lopez On 07/07/2025 at 01:16 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SALVATION ARMY ALEGRIA, THE
FACILITY NUMBER: 198203250

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87888(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by residents to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Water temperature measured 126.5 - 130.1 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2025
Plan of Correction
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Administrator will adjust water temperature, keep log for 3 days, and send as proof to LPA by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Alberto Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2025


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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SALVATION ARMY ALEGRIA, THE
FACILITY NUMBER: 198203250
VISIT DATE: 07/07/2025
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(Continued from 809)

Operational Requirements: The facility has the appropriate fire clearance. The last Fire/Emergency Drill was conducted on 05/14/25. There is an outdoor activity area / playground that is shaded and furnished for outdoor use.

Staffing: There appears to be sufficient staffing at all times in the facility. Administrator Jocelyn Anguiano has a valid administrator certificate that expires on 02/08/26.

Personnel Records-Training: Staff have criminal record clearance. Staff have current CPR/first aid training and sufficient on-going training.

Client Rights-Information: Facility provides internet and telephone access for the clients in care.

Client Records-Incident Reports: Client files are kept in a secure location and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.

Food Service: The kitchen was observed for its ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.

Health Related Services: Medications for residents are securely stored on the 2nd floor in the CNA Room. All medications observed during the visit were properly labeled and in their original containers.

Incidental Medical & Dental: The facility does not have clients in care that require treatment or observation by appropriately skilled professionals for more than 8 hours a day.

Disaster Preparedness: The facility has an Emergency Disaster Plan with evacuation procedures, emergency contact numbers, location of shut off valves and at least 2 relocation sites. Facility has a Disaster Mass Casualty Plan with documented drills that are done regularly and maintained at the facility.

LPA conducted 3 staff interviews and 3 client interviews during today’s visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiency observed during today’s visit is documented on 809(D).

An exit interview was held, and a copy of the report, 809D and appeal rights was provided to Director Ana Aguirre

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2025
LIC809 (FAS) - (06/04)
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