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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204998
Report Date: 05/17/2026
Date Signed: 05/17/2026 03:56:40 PM

Document Has Been Signed on 05/17/2026 03:56 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ANZA HOME CAREFACILITY NUMBER:
198204998
ADMINISTRATOR/
DIRECTOR:		RODRIGO RAMOSFACILITY TYPE:
740
ADDRESS:19917 ANZA AVENUETELEPHONE:
(310) 370-9613
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY: 6CENSUS: 4DATE:
05/17/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Caregiver - Jesus Marie QuiboteTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 05/17/2025, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) staff conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Caregiver, Jesus Marie Quibote. The purpose of the visit was explained and the LPA was allowed entry to the facility.

The facility is licensed to operate for (1) non-ambulatory and cleared for (5) bedridden elderly residents ages 60 and above. The facility is approved for (6) hospice residents.

The Annual Licensing Fees are current.

Facility Layout: The facility is a single-story house located in a main street. It consists of the following: 5 resident bedrooms; 2 common full bathrooms; 1 staff bedroom; 1 great room which consist of a living room area, dining room area, and kitchen area; 1 attached garage with a laundry area; and a backyard outside patio area.

Outside Grounds: were toured no bodies of water were observed, walkways around the home were not cleared of hazards (pictures were taken).
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2026
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 05/17/2026 03:56 PM - It Cannot Be Edited


Created By: Socorro Leandro On 05/17/2026 at 01:44 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ANZA HOME CARE
FACILITY NUMBER: 198204998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in Staff 1 (S1) not being associated to the facility (S1's hire date is 4/14/2025) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2026
Plan of Correction
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The Licensee will associate S1 to the facility.
The Licensee will create a plan to ensure that before hire date staff are associated to the facility.
The Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov
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.
Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:
Socorro Leandro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/17/2026 03:56 PM - It Cannot Be Edited


Created By: Socorro Leandro On 05/17/2026 at 01:44 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ANZA HOME CARE
FACILITY NUMBER: 198204998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in room 1's outside exit door not being able to open, great room's sliding door not being to open completely, the garage is overcrowded with items, facility refrigerators/freezers are not clean, outside grounds were not cleared of hazards which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2026
Plan of Correction
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The Licensee will fix room 1's outside exit door and the great room's sliding door. The Licensee will declutter the garage and the outside grounds. The Licensee will clean and organize the reiterators/freezers. The Licensee will email pictures and videos to Socorro.Leandro@dss.ca.gov

The Licensee will create a plan to maintain the facility in good repair, clean, safe, and sanitary at all times and email plan to Socorro.Leandro@dss.ca.gov
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.
Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:
Socorro Leandro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2026


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 05/17/2026 03:56 PM - It Cannot Be Edited


Created By: Socorro Leandro On 05/17/2026 at 01:44 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ANZA HOME CARE
FACILITY NUMBER: 198204998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in Staff 1 (S1) not having a health screening report and Staff 2 (S2) not having a tuberculosis test result which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2026
Plan of Correction
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The Licensee will email S1’s health screening report and S2’s tuberculosis test result.
The Licensee will create a plan to stay in compliance.
Email proof of correction to Socorro.Leandro@dss.ca.gov

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:
Socorro Leandro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2026


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 05/17/2026 03:56 PM - It Cannot Be Edited


Created By: Socorro Leandro On 05/17/2026 at 01:44 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ANZA HOME CARE
FACILITY NUMBER: 198204998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.319(a)
Regulations
(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for resident use.

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 in having internet but not having a videoconferencing device available to residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2026
Plan of Correction
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The Licensee will place a videoconferencing device in the facility dedicated to residents in care. The Licensee will create a plan to ensure that residents always have a videoconferencing device available to them.
Email proof of correction to: Socorro.Leandro@dss.ca.gov
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

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 in having foods in the refrigerator and pantry whose "best by date" had passed (e.g. Best By JAN0925) and spoiled vegetables (which looked moldy with green and black colors) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2026
Plan of Correction
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The Licensee will clean and organize the refrigerators/freezers, pantries/cabinets, food storage areas and dispose of any foods that are not of good quality. The Licensee will create a plan to maintain food in good quality.
Email proof of correction to Socorro.Leandro@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:
Socorro Leandro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2026


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 05/17/2026 03:56 PM - It Cannot Be Edited


Created By: Socorro Leandro On 05/17/2026 at 01:44 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ANZA HOME CARE
FACILITY NUMBER: 198204998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in not having complete records for Residents 1 (R1) to Resident 4 (R4) (missing/incomplete records ranging from Admission Agreements, doctors’ orders full to half bed rails, home health records) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2026
Plan of Correction
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The Licensee will email Socorro.Leandro@dss.ca.gov complete records for R1 to R4.
The Licensee will create a plan to ensure that resident records are complete and current and are available to staff in the facility. Email proof of correction to Socorro.Leandro@dss.ca.gov
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:
Socorro Leandro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2026


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: ANZA HOME CARE
FACILITY NUMBER: 198204998
VISIT DATE: 05/17/2026
NARRATIVE
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Kitchen Area/Facility Food: The facility has supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept inaccessible to residents in care. There is fire extinguisher near the kitchen and it was last serviced on 03/26/2025. There were food items that were not of good quality (pictures were taken). For example, some food items best by date had passed, freezer burn meats, and spoiled vegetables. The refrigerators/freezers were not clean (pictures were taken). There is a landline telephone in the kitchen.

Great Room: There is activity work available to residents, for example puzzles and painting materials. There is no videoconferencing device available to residents. The sliding window door is in disrepair.

Resident Bedrooms: 5 out of 5 resident bedrooms were toured. There is adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Room 1’s exit door is in disrepair.

Bathrooms: Toilets, showers, and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries are accessible to residents. The hot water temperature measured 116.4 Fahrenheit.

Medications: were inaccessible to residents in care.

Garage: is not clear of hazards, there is a pile of items, supplies, and equipment that made it impossible to walk around the garage (pictures were taken).

Miscellaneous: Documents are posted as mandated. The Liability Insurance, Infection Control Plan, Emergency Disaster Plan, Emergency Disaster Drills, Plan of Operation, Fire Inspection were not present in the facility to review.

2 staff records were reviewed, 2 out of 2 staff records were incomplete. Staff 1 (S1) did not have a CPR/First Aid Certificate, Health Screening Report, and is not associated with the facility. Staff 2 (S2) did not have a Tuberculosis Test Result.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2026
LIC809 (FAS) - (06/04)
Page: 8 of 9
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: ANZA HOME CARE
FACILITY NUMBER: 198204998
VISIT DATE: 05/17/2026
NARRATIVE
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4 resident records were reviewed, 4 out of 4 resident records did not have current and complete records. Resident 1 (R1) did not have an Admission Agreement and Doctors Order for a Full Bedrail, and incomplete Home Health records and Appraisal. Resident 2 (R2) did not have an Admission Agreement. Resident 3 (R3) had an incomplete Admission Agreement and Home Health records, and did not have a Doctors Order for Half Bedrails. Resident 4 (R4) did not have a Doctors Order for Half Bedrails and an Admission Agreement, and had incomplete Home Health records.

Deficiencies are being cited based on observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, see LIC809Ds. A civil penalty is being provided regarding staff association.

An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Caregiver, Jesus Marie Quibote.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2026
LIC809 (FAS) - (06/04)
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