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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320282
Report Date: 08/06/2025
Date Signed: 08/06/2025 04:54:42 PM

Document Has Been Signed on 08/06/2025 04:54 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:ACOSTA FAMILY HOME IIFACILITY NUMBER:
198320282
ADMINISTRATOR/
DIRECTOR:		ACOSTA, ASHLEYFACILITY TYPE:
735
ADDRESS:1811 EAST ABILA STREETTELEPHONE:
(310) 604-8740
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 4CENSUS: 4DATE:
08/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Sayra Ramos TIME VISIT/
INSPECTION COMPLETED:
12:27 PM
NARRATIVE
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On 08/06/25, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Direct Support Provider Sayra Ramos. LPA explained the purpose of today’s visit. The facility is licensed to operate for (3) ambulatory and (1) non-ambulatory adults ages 18 through 59. The residents are all Harbor Regional Center consumers.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (4) client's rooms, (2) bathrooms (1) staff bathroom, a living area, a dining area, a kitchen, an office, an outside seating area, and a garage.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 105.9 degrees F. A comfortable temperature of 77 degrees F. was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. A fire extinguisher was charged. A review of the Medication Records Administration (MAR) was observed to be maintained in place.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms.
(Evaluation Report continues LIC 809-C)
NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Ernand Dabuet
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2025
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 08/06/2025 04:54 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 08/06/2025 at 10:56 AM
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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ACOSTA FAMILY HOME II
FACILITY NUMBER: 198320282

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Type B
Section Cited
CCR
80088(e)(3)
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

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. LPA identified bathroom #2 had low water pressure and sink has slow drainage or water standing water. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2025
Plan of Correction
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Licensee shall have the facility in good repair at all times. Licensee will ensure bathroom #2's water pressure is adjusted sink drainage is working properly with no backflow of standing water. Proof of correction must be sent by video to ernand.dabuet@dss.ca.gov by due date 08/20/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Ernand Dabuet
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/06/2025 04:54 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 08/06/2025 at 10:57 AM
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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ACOSTA FAMILY HOME II
FACILITY NUMBER: 198320282

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(e)
Administrator Qualifications and Duties
(e) The administrator shall be on the premises the number of hours necessary to manage and administer the facility in compliance with applicable law and regulation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPA was notified that administrator is not spending the require number of hours necessary to manage the facility. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2025
Plan of Correction
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Licensee shall adhere to Title 85064(e) regulations and review the regulations. Licensee will notify adminsitrator in writing a schedule is being spent at the facility and an updated LIC 500 Personnel Report submitted to LPA Dabuet by due date 08/20/25 in office meeting.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

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. LPA was notified that no record emergency fire drills available for licensing to inspect. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2025
Plan of Correction
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Licensee will ensure to adhere to Health and Safety 1565(c) and conduct emergency drills at least quarterly with a log for verification. Proof of correction must be submitted to LPA Dabuet by due date 08/20/25 at in office meeting.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Ernand Dabuet
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/06/2025 04:54 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 08/06/2025 at 11:05 AM
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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ACOSTA FAMILY HOME II
FACILITY NUMBER: 198320282

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(d)
80070 Client Records (d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. Licensee failed have client's records for licensing to audit or review client's records during normal business hours. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2025
Plan of Correction
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Licensee shall have available to the licensing agency to inspect, audit and review of all client's records during normal business hours. Licensee will notify LPA Dabuet when records are available to inspect by due date 08/20/25 at in office meeting.
Type B
Section Cited
CCR
80066(d)
80066 Personnel Records (c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. Licensee failed to have available personnel records for licensing to inspect and audit during business hours. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2025
Plan of Correction
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80066 Personnel Records
Licensee shalle have all personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Proof of correction licensee, will notify LPA Dabuet when records are available for audit by 08/20/2025 at in office meeting.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Ernand Dabuet
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
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: ACOSTA FAMILY HOME II
FACILITY NUMBER: 198320282
VISIT DATE: 08/06/2025
NARRATIVE
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LPA observed First Aid Kit was maintained. A working landline phone was operational. The facility had operational smoke and carbon monoxide in bedrooms and common areas.

The facility is current with CCL annual dues. The facility has current administrator's certificate for Ashley Acosta #7012005735 06/14/2024 through 06/13/2026.

DEFICIENCIES:
  • Personnel records were not available for inspection during the visit.
  • Client records were not available for inspection during the visit
  • Administrator shall be on the premises the number of hours necessary to manage and administer the facility.
  • Bathroom #2 faucet water pressure is low and has slow drainage with standing water.
  • Facility did not have proof of fire drills have been performed on a quarterly basis.


According to the California Code of Regulations (Title 22, Division 6, Chapter 1), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).

An exit interview was conducted with Sayra Ramos and a copy of the report was provided.



Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *







NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Ernand Dabuet
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
LIC809 (FAS) - (06/04)
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