198204584-3-26-2025-11-AS-EDAT-DF642G-20250326184309

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204584
Report Date: 03/26/2025
Date Signed: 03/26/2025 06:43:16 PM

Document Has Been Signed on 03/26/2025 06:43 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:	VILLA ANGELA RESIDENTIAL HOME		FACILITY NUMBER:	198204584
ADMINISTRATOR/ DIRECTOR:	SHIRLEY DANTING		FACILITY TYPE:	740
ADDRESS:	23528 FIGUEROA STREET		TELEPHONE:	(310) 835-6773
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	03/26/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:01 PM
MET WITH:	Shirley Danting		TIME VISIT/ INSPECTION COMPLETED:	04:02 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 March 26, 2025, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with licensee Shirley Danting and explained the purpose of today’s visit. The facility is licensed for (6) non-ambulatory elderly residents ages 60 and above and is approved for (4) hospice residents. The facility is a single-story structure located in a residential neighborhood. It consists of (5) residents' rooms, (2) shared bathrooms, a living area, a dining area, a kitchen, and an outside covered patio area. LPA and licensee toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition; adequate lighting and storage for the residents' personal belongings were observed. Bed linens, comforters, and bath towels were adequately stocked during the visit. Bathrooms were found to be within Title 22 regulations and were clean and operational—the water temperature measured 120.0 F. A comfortable temperature of 72 degrees was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished during the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and inaccessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was appropriately maintained. The facility has (1) a fire extinguisher that was charged, smoke detectors, and carbon monoxide alarms. LPA reviewed Medication Administration Records (MAR), revealed accurate and maintained in order. The facility conducted a Fire/Safety Drill on 01/10/25. A working landline telephone remains available. Evaluation Report Continues on LIC 809-C

Janae Hammond	TELEPHONE: (424) 544-1027
Ernand Dabuet	TELEPHONE: (323) 629-5526
	DATE: 03/26/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025

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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: VILLA ANGELA RESIDENTIAL HOME	FACILITY NUMBER: 198204584
	VISIT DATE: 03/26/2025

NARRATIVE

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During the visit, LPA observed the facility's infection control practices. Staff followed screening protocols for visitors, staff, and residents and sanitized stations in common areas and restrooms. The facility has a 30-day supply of Personal Protective Equipment (PPE). Posters mandated for inspection control were posted.

An audit of residents #1-#6 (R1-R6) service records and staff #1-#6 (S1-S6) personnel records revealed that they are complete. The facility has current liability insurance coverage effective 06/22/24 through 06/22/25. The facility is current on Community Care Licensing annual dues. The facility has a current administrator certificate for Shirley Danting #7005186740, expiring 07/25/26.

No deficiencies were cited during this inspection visit.

An exit interview was conducted with Shirley Danting, and a copy of the report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025

LIC809 (FAS) - (06/04)

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