198601751-3-20-2025-11-AS-WGIS-DEXRS2-20250320131600

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601751
Report Date: 03/20/2025
Date Signed: 03/20/2025 01:16:16 PM

Document Has Been Signed on 03/20/2025 01:16 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:	ANGELIC CARE OF SOUTH BAY		FACILITY NUMBER:	198601751
ADMINISTRATOR/ DIRECTOR:	JENNIFER SAN AGUSTIN		FACILITY TYPE:	740
ADDRESS:	2619 W. 231ST STREET		TELEPHONE:	(310) 539-2866
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	03/20/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:11 AM
MET WITH:	Charesa Reyes		TIME VISIT/ INSPECTION COMPLETED:	01:00 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 03/20/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit using the CARES tool. LPA met with House Manager, Charesa Reyes, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The facility is licensed to operate for six (6) non-ambulatory elderly adults of which two (2) may be bedridden with an approved hospice waiver for four (4). Currently, there are 6 residents residing in the facility. Physical Plant/Structure The facility is a single-story home in a residential neighborhood. The facility consists of five (5) resident bedrooms, three (3) bathrooms, living room areas, dining room, kitchen, staff room, office area, attached garage with laundry area, and backyard with shaded patio with table and chairs. LPA did not observe any bodies of water on the premises. LPA observed all walkways around the facility were clean, clear, and free of debris, hazards, and obstructions. Bedrooms During the facility tour, LPA inspected all resident bedrooms. LPA observed resident bedrooms have the required items including bed, dresser, chair, nightstand, and storage space for resident’s personal belongings. LPA observed resident beds have the required linens including a mattress cover, fitted sheets,

Eva M Alvarez	TELEPHONE: (323) 981-1755
Wendy Gibbs	TELEPHONE: (323) 981-1755
	DATE: 03/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025

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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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: ANGELIC CARE OF SOUTH BAY	FACILITY NUMBER: 198601751
	VISIT DATE: 03/20/2025

NARRATIVE

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blanket, comforter, and pillows. LPA observed the rooms to be clean and in good repair. LPA observed an ample supply of bed linens, blankets, and comforters stored in a closet in the garage. All bedrooms have ample lighting.
Bathrooms LPA inspected all resident bathrooms and observed them to be operable within Title 22 regulations. LPA observed all showers to be clean and free of mildew and mold. All safety handrails are securely fastened. LPA observed nonskid mats and shower chairs in the showers. LPA observed an ample supply of toiletries for residents. The water temperature in the bathrooms measured 106.5-degrees, 109.1-degrees, and 109.4-degrees Fahrenheit.
Kitchen LPA inspected the kitchen and found it to be clean and sanitary. All appliances were observed operational and in good repair. LPA observed an ample supply of cookware, dishware, and cutleries. LPA observed a 3-day supply of perishable foods and 7-day supply of nonperishable foods. LPA observed knives and sharps secured in a locked drawer. All cleaning supplies were observed secured in the locked cabinet under the sink. An additional supply of cleaning products were observed secured in a locked cabinet in the garage.
Common Areas During the facility inspection, LPA observed two (2) living room areas available for resident use. One area three (3) recliners for resident use and the other has two (2) couches available for resident use. LPA observed reading material and other activities for resident use. During today’s visit, LPA observed residents participating in exercise and activities. The dining room has a large table with chairs to accommodate all residents. LPA observed the facility to be appropriately furnished at the time of visit. All rooms were observed clean and in good repair. LPA observed all rooms have ample lighting. All walkways and

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025

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: ANGELIC CARE OF SOUTH BAY	FACILITY NUMBER: 198601751
	VISIT DATE: 03/20/2025

NARRATIVE

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hallways in the home were observed clean, clear, and free of obstructions and hazards. The facility was maintained at a comfortable temperature.
Files LPA reviewed the files for six (6) residents and observed six (6) out of six (6) residents file have the required documents. LPA reviewed the Administrators files, and observed they have the required documents, training, and certification. LPA observed Administrator Certificate for both administrators are valid till 06/01/2025 and 05/13/2025. LPA received and reviewed a copy of the facility Liability Insurance through Acord policy number BID587524-00 valid till 07/31/2025. LPA observed Licensing Fees are current.
Medications LPA observed Centrally Stored Medications secured in a locked cabinet in the hallway. LPA observed all medications were in their original containers. LPA reviewed the medications and Medication Administration Record (MAR) for six (6) residents. LPA observed six (6) out of six (6) resident’s medications are consistent with properly documented records.
Safety LPA observed two (2) fully charged fire extinguisher purchased on 03/05/2024. LPA observed smoke detectors and carbon monoxide detectors are operable. The last Emergency Drill was conducted on 03/01/2025. The last annual fire inspection and sprinkler inspection was conducted by Torrance Fire Department on 03/04/2025. The Emergency and Disaster Plan (LIC610E) was last reviewed and updated on 09/01/2024. LPA observed an ample supply of emergency water and food supply. All exits are clearly marked with an EXIT sign. All doors have an alarm that chimes when the door is opened. The facility has a working landline telephone. LPA observed a First Aid kit with the required items and a current manual. There are no firearms or ammunition on the premises.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025

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: ANGELIC CARE OF SOUTH BAY	FACILITY NUMBER: 198601751
	VISIT DATE: 03/20/2025

NARRATIVE

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Infection Control Upon entry, LPA observed a sanitizing station that consisted of a Visitor Sing in log, hand sanitizer, thermometer, and masks available. LPA observed all staff wearing face masks. LPA observed required Infection Control signs posted in the facility.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies therefore no citations were issued at this time.

An exit interview was conducted with House Manager, Charesa Reyes, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025

LIC809 (FAS) - (06/04)

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