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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320274
Report Date: 01/27/2025
Date Signed: 01/27/2025 02:06:09 PM

Document Has Been Signed on 01/27/2025 02:06 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:ANGEL HOUSE, THEFACILITY NUMBER:
198320274
ADMINISTRATOR/
DIRECTOR:		MICHELLE MARSHALL-CAIQUOFACILITY TYPE:
735
ADDRESS:5103 W. 123RD PLACETELEPHONE:
(562) 405-7316
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY: 3CENSUS: 1DATE:
01/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Administrator/Licensee - MICHELLE MARSHALL-CAIQUOTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 1/27/2024, 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 the Licensee/Administrator, Michelle Marshall-Caiquo. CCLD staff explained the purpose of the visit and was accompanied by a staff member inside and outside the facility during this inspection.

This facility is licensed to serve 3 ambulatory adults ages 18 to 59 years old.

A total of 1 client is currently residing in this facility.

On 1/24/2025, Licensee dropped of a check to El Segundo Regional Office of $1,110 for Annual Licensing Fees.

Facility Layout: The facility is a one-story house located in a residential street. The home consists of 3 client bedrooms, 2 full bathrooms, a great room that consist of a living room area, a dining room area and a kitchen area, and a backyard patio area with shaded seating.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025
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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Document Has Been Signed on 01/27/2025 02:06 PM - It Cannot Be Edited


Created By: Socorro Leandro On 01/27/2025 at 01:39 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: ANGEL HOUSE, THE
FACILITY NUMBER: 198320274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

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 4 out of 5 staff not having their Tuberculosis test results which poses a potential health risk to persons in care.
POC Due Date: 02/18/2025
Plan of Correction
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The Licensee/Administrator agreed to submit staff tuberculosis test results 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.
SUPERVISOR'S NAME:Ulysses Coronel
LICENSING EVALUATOR NAME:Socorro Leandro
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2025


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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: ANGEL HOUSE, THE
FACILITY NUMBER: 198320274
VISIT DATE: 01/27/2025
NARRATIVE
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Outside Grounds: were toured no bodies of water were observed, walkways around the home were clear of hazards, and there are no security bars or weapons on the premises.

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 clients in care. There is a fire extinguisher in the kitchen area. There is a landline telephone.

Living Room Area: There is a videoconferencing device, games/activity work (i.e. board games, books, magazines, newspapers), and couches.

Client Bedrooms: 3 out of 3 client bedrooms were toured. There is adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition.

Bathrooms: Toilets, showers, and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to clients.

Medications: were inaccessible to client in care. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
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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: ANGEL HOUSE, THE
FACILITY NUMBER: 198320274
VISIT DATE: 01/27/2025
NARRATIVE
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Miscellaneous: Documents are posted as mandated. Last gas/fire drill was conducted on 12/30/2024. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational.

5 staff records were reviewed, 4 out 5 staff did not have their Tuberculosis Test Results.

1 client record was reviewed and, 1 out of 1 client record had required documentation. A technical advisor is being provided regarding Medication.

A deficiency is being cited based on record review in accordance with the California Code of Regulations, Title 22. A deficiency regarding staff Tuberculosis Test Results. 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 Licensee/Administrator.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
LIC809 (FAS) - (06/04)
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