198320294-1-21-2026-11-AS-WGIS-DQK3LY-20260121172132

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320294
Report Date: 01/21/2026
Date Signed: 01/21/2026 05:21:43 PM

Document Has Been Signed on 01/21/2026 05:21 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:	ACTIVE CARE HOME 1		FACILITY NUMBER:	198320294
ADMINISTRATOR/ DIRECTOR:	CANTORIA, MARIA L.		FACILITY TYPE:	735
ADDRESS:	20545 MADISON ST.		TELEPHONE:	(310) 370-3748
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90503
CAPACITY: 4		CENSUS: 4	DATE:	01/21/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:56 PM
MET WITH:	Mary Magaben		TIME VISIT/ INSPECTION COMPLETED:	05:00 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 01/21/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced 1-year Required Annual Visit. LPA met with House Manager, Mary Magaben, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The facility is licensed to serve four (4) ambulatory clients, two (2) of which may be non-ambulatory, and two (2) of which may be bedridden. The facility has an approved hospice waiver for four (4) clients. There are currently four (4) Clients residing in the facility. Physical Plant/Structure The facility is a single-story structure in a residential neighborhood. It consists of four (4) Client bedrooms, three (3) bathrooms, an office, living room, dining room, kitchen, pantry, attached garage, and shaded patio area. All walkways outside the facility were observed clean, clear, and free of debris, hazards and obstructions. The shaded patio has a table and chairs available for client use. Bedrooms LPA inspected all client rooms and observed them to be clean and in good repair. All rooms were observed with the required furniture including a bed, dresser, nightstand with lamp, chair and ample storage space for residents’ personal belongings. LPA observed beds have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. LPA observed an ample supply of bed linens in good repair. Bathrooms LPA inspected client’s bathrooms and observed them to be within Title 22 Regulations. LPA observed the toilet, faucets and showers working properly. LPA observed secured safety handrails, shower chairs, and non-skid material in the shower. LPA observed the showers to be clean and free of mildew and/or mold. The water temperature measured 106.2- degrees, 107.9- degrees, and 109.5- degrees Fahrenheit. LPA observed an ample supply of bath towels, toiletries, and personal hygiene supplies were adequately stocked.

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026

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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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: ACTIVE CARE HOME 1	FACILITY NUMBER: 198320294
	VISIT DATE: 01/21/2026

NARRATIVE

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Kitchen LPA inspected the kitchen and observed it clean and sanitary. LPA observed all appliances are operable and in good repair. LPA observed an ample supply of cookware, dishware, and cutlery. LPA observed a 3-day supply of perishable foods and a 7-day supply of non-perishable foods properly stored and labeled. LPA observed knives and sharps secured in a locked drawer in the kitchen and are inaccessible to clients. LPA observed cleaning supplies secured in a locked cabinet under the kitchen sink and are inaccessible to clients. The water temperature measured 108.2- degrees Fahrenheit.
Common Rooms During the time of visit, LPA observed the facility to be appropriately furnished. In the sitting room, LPA observed a couch available for client use. In the living room, LPA observed a couch and chairs to accommodate clients. The dining room has a large table and chairs to accommodate clients. LPA observed an ample supply of games, activities, and reading materials available for clients. The facility was maintained at a comfortable temperature.
Files LPA reviewed the files for four (4) residents, LPA observed all files have the required documents. LPA reviewed Client’s P & I and observed them to be consisted with documented records and receipts. LPA reviewed the files for the Administrator and three (3) staff, LPA observed the staff files have the required documents, training, certification, and clearance. LPA observed that the administrators Administrator Certificate #7032390735 is valid till 11/04/2026. During file review LPA observed Licensing Fees are current. LPA received and reviewed a copy of the Surety Bond.
Medications LPA observed medications secured in a locked cabinet in the dining area. LPA observed all medications in their original packaging. LPA reviewed the medication and Medication Administration Record (MAR) for four (4) residents. LPA observed four (4) out of four (4) residents’ medication is consistent with properly documented records.
Safety LPA observed smoke and carbon monoxide detectors are operable. LPA observed a fire extinguisher mounted on the wall in the kitchen that purchased on 01/18/2026. The last Emergency Drill was conducted on 12/14/2025. The last Fire Prevention Inspection was conducted by the Torrance Fire Department in December 2025. LPA inspected the First Aid kit and observed it has the required items and a current manual. The facility has a current Emergency and Disaster Plan posted in the facility. LPA received and reviewed the Liability Insurance through Acord that is valid till 03/24/2026.
Infection Control LPA observed a sanitizing station at the entrance of the facility. The sanitizing station consists of a Visitor Sign-In Log, hand sanitizer, masks, gloves, and a thermometer to take temperatures. LPA observed a Personal Protective Equipment (PPE) cart next to the sanitizing station. LPA observed a 90-day supply of PPEs stored in a shed in the back. LPA observed an ample supply of cleaning products secured in a cabinet in the garage and an ample supply of paper towels.

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026

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: ACTIVE CARE HOME 1	FACILITY NUMBER: 198320294
	VISIT DATE: 01/21/2026

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 26 27 28 29 30 31 32	During today’s visit, LPA did not observe or cite any deficiencies. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted with House Manager, Mary Magaben, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026

LIC809 (FAS) - (06/04)

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