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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600180
Report Date: 04/07/2026
Date Signed: 04/07/2026 12:20:14 PM

Document Has Been Signed on 04/07/2026 12:20 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ANGELINA HOME AND CARE IIIFACILITY NUMBER:
198600180
ADMINISTRATOR/
DIRECTOR:		ADELINA B. ESGUERRAFACILITY TYPE:
735
ADDRESS:3036 LA PUENTE ROADTELEPHONE:
(909) 598-8323
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 6CENSUS: 5DATE:
04/07/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:12 AM
MET WITH:Flordeliza Rosana, CaregiverTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Noemi Galarza made an unannounced annual inspection visit. The purpose of the visit was explained to reliever staff Angelina Respicio. Caregiver staff Flordeliza "Lourdes" Rosana arrived later. Licensee/Administrator was notified telephonically of the visit. The facility is an Adult Residential Facility (ARF) that serves mentally disabled residents ages 59 and under.

The following were observed/inspected:

Infection Control: The Infection Control Plan includes Environmental cleaning and disinfection activities.

Physical Plant/Environment Safety: The facility is a single story home consisting of 4 bedrooms [3 resident & 1 live-in staff room], 2 bathrooms, kitchen, dining room, living room, attached 2-car garage with laundry area and additional refrigerators, and an outdoor backyard patio area. The front yard is landscaped with grass and the rear backyard has cement. Smoke and carbon monoxide detectors were tested and are operational. The facility has one (1) fire extinguisher and a fire pull alarm. Water temperature readings did not measure within the required 105 - 120 degrees Fahrenheit. The facility has a 1st Aid Kit and Manual. Cleaning supplies, knives, and toxic substances are inaccessible to residents. Exit doors are free of any obstruction and there are no pools or large bodies of water.

* There are 2 cats in the home. A mattress, shower chair, walker, and storage boxes were observed in the backyard patio area.

Operational Requirements: Fire clearance is approved for six (6) ambulatory residents. Care and supervision to meet the clients needs was observed. Special equipment and supplies are not used by residents. The facility does not handle resident monies. Therefore a Surety Bond is not required.



Staffing: A total of 3 staff members provide care and supervision to the clients.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2026
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ANGELINA HOME AND CARE III
FACILITY NUMBER: 198600180
VISIT DATE: 04/07/2026
NARRATIVE
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Personnel Records/Staff Training: Administrator certificate expires 3/26/2027. Three (3) staff files were reviewed. Staff have criminal background clearance, health and TB clearance, and 1st Aid/CPR training. However, training has not been conducted since 4/12/2025.

Client Rights/Information: Physician orders, and personal rights were reviewed in client files.

Client Records/Incident Reports: Five (5) resident files were reviewed. Admission agreements, Physician's Report, medical/functional assessments, TB clearance, personal rights, medical consent, Appraisal Needs & Services Plans, and Medication Administration Records were reviewed.

Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable, 7 day non-perishable food, and emergency supply of food and water. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. None of the residents have modified diet orders.

Health Related Services: Residents are assisted with self administration of prescription and non-prescription medications. Centrally stored resident medication records and 30-Day supply of medications were reviewed. A deficiency was observed with R1's Medication Administration Record (MAR) and bubble pack directions.

Incident Medical and Dental: Residents have updated consultant assessments, Physician Reports, and COVID-19 vaccination cards on file.

Disaster Preparedness, and Emergency Intervention: Emergency Disaster Plan was reviewed. The plan shall be reviewed annually, updated as necessary, and maintained on file at the facility. First Aid Kit and Manual were observed. The last emergency drill was conducted on 3/26/2026.

Emergency Intervention: Manual restraints are not utilized by staff.

Pursuant to Title 22, deficiencies are cited in LIC 809D.

An exit interview was conducted with caregiver Flordeliza Rosana. A copy of the report and appeal rights was provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/07/2026 12:20 PM - It Cannot Be Edited


Created By: Noemi Galarza On 04/07/2026 at 11:31 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ANGELINA HOME AND CARE III
FACILITY NUMBER: 198600180

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 that the bathroom hot water readings were 123.6, 127.2 and kitchen measured 123.8 DF, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
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Administrator shall submit a hot water temperature log indicating the water was tested 3 times a day today and tomorrow and it is within 105-120DF. . POC is due tomorrow
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

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 that R1's Fenofibrate 145 mg MAR states it should be given at bedtime, but bubble pack has a "morning" sticker and staff have been administering the medication in the morning, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
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Caregiver contacted the pharmacy and confirmed that the medication should be administered at bedtime. Administrator shall:
1. Notify R1's MD about medication administration error.
2. Submit a written plan of correction that addresses the medication error and Title 22, 80075 .
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 04/07/2026 12:20 PM - It Cannot Be Edited


Created By: Noemi Galarza On 04/07/2026 at 11:31 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ANGELINA HOME AND CARE III
FACILITY NUMBER: 198600180

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, 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 because the backyard patio area has a mattress, storage boxes, shower chair, and walker, and R1's room is cluttered preventing access to the closet, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2026
Plan of Correction
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Administrator shall remove all furniture stored in the backyard patio and assist R1 in organizing/cleaning their room. Submit picture evidence of the patio area and R1's room.
Type B
Section Cited
CCR
80065(f)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

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 because continuation education training documents show that the last in-service training was conducted on 4/12/25 for a total of 4 hours, no additional training has been provided since, which poses a potential health, safety or personal rights risk to persons in care.

POC Due Date: 04/28/2026
Plan of Correction
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Administrator shall conduct regular in-service training. Submit proof of in-service training for all staff, including reliever staff (S3).
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2026


LIC809 (FAS) - (06/04)
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