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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320286
Report Date: 04/09/2026
Date Signed: 04/10/2026 08:15:38 AM

Document Has Been Signed on 04/10/2026 08:15 AM - 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 IFACILITY NUMBER:
198320286
ADMINISTRATOR/
DIRECTOR:		ACOSTA, ASHLEYFACILITY TYPE:
735
ADDRESS:1540 EAST CYRENE DRIVETELEPHONE:
(310) 997-5615
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 4CENSUS: 3DATE:
04/09/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:34 PM
MET WITH:Anet Alegria TIME VISIT/
INSPECTION COMPLETED:
04:40 PM
NARRATIVE
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On April 9, 2026, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced case management visit at the facility. The Direct Support Provider, Anet Alegeria, greeted LPA Dabuet. The LPA explained to Anet Alegeria that the visit was in association with a complaint visit 11-AS-20260330161931 conducted on April 1, 2026.

On April 1, 2026, between 10:30 PM and 11:50 PM, (LPA) Dabuet along with Mercedes Lowrey and Juan Bermudes of Harbor Regional Center observed the following deficiencies during the complaint visit.

The licensee is in violation of Title 22 80066(c); 80070(d) and 80070(b)(g).



Hazardous items were discovered in an open, unlocked cabinet in areas accessible to clients, including the garage, where one client was sitting nearby. Additionally, client and staff records were left on the dining room table, with binders and files stored in an open-shelf cabinet, exposing sensitive information to unauthorized access. Furthermore, personnel files are not maintained, complete, and available to the licensing agency for review during inspection visit on April 1, 2026.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed, and a citation has been issued (ref. LIC 809-D).

An exit interview was conducted, and Direct Support Provider Anet Alegria provided with a copy of the report and Appeal Rights.

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Ernand Dabuet
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2026
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 04/10/2026 08:15 AM - It Cannot Be Edited


Created By: Ernand Dabuet On 04/09/2026 at 03:54 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ACOSTA FAMILY HOME I
FACILITY NUMBER: 198320286

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/10/2026
Section Cited
CCR
80090(b)(g)

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80090 (b) All clients shall be protected against hazards within the facility through provision... (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
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Licensee is to adhere to Title 22 Reg 80090(b)(g) and to ensure to have all hazardous materials stored in locked cabinets. POC is to be submitted to LPA Dabuet at ernand.dabuet@dss.ca gov by 04/10/26.
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Based on interview and observation, Licensee did not provide safe accomodations for clients by leaving hazardous material left unattended and accessible to clients. This violation poses a immediate health and safety risks to clients in care.
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Type B
04/16/2026
Section Cited
CCR80066(c)

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80066 (c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours...

This requirement is not met as evidenced by:
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Licensee is to adhere to Title 22 Reg 80066(c) and to ensure that all personnel files/records are maintained on the premises and avalable for licensing agency to inspect and audit. POC is to be submitted to LPA Dabuet at ernand.dabuet@dss.ca gov by 04/16/26.
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Based on interview and observation, Licensee did not have personnel files availabe to audit inspection visit on 04/01/26. This violation poses a poetential health and safety risks to clients in care.
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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.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Ernand Dabuet
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2026


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/10/2026 08:15 AM - It Cannot Be Edited


Created By: Ernand Dabuet On 04/09/2026 at 04:13 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ACOSTA FAMILY HOME I
FACILITY NUMBER: 198320286

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/16/2026
Section Cited
CCR
80070(c)

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80070 (c) All information and records obtained from or regarding clients shall be confidential.

This requirement is not met as evidenced by:
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Licensee is to adhere to Title 22 Reg 80070(c) and to ensure that all clients files are stored in secure storage and remain confidential. POC is to be submitted to LPA Dabuet at ernand.dabuet@dss.ca gov by 04/16/26.
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Based on interview and observation, Licensee did not ensure to store clients files records in secure locked storage and were left on the dining room table. This violation poses a poetential health and safety risks to clients in care.
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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.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Ernand Dabuet
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2026


LIC809 (FAS) - (06/04)
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