198602619-1-25-2026-11-AS-FSHY-DQDUHA-20260116143536

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602619
Report Date: 01/16/2026
Date Signed: 01/25/2026 08:48:01 PM

Document Has Been Signed on 01/25/2026 08:48 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 III		FACILITY NUMBER:	198602619
ADMINISTRATOR/ DIRECTOR:	ACOSTA, ASHLEY		FACILITY TYPE:	735
ADDRESS:	875 S ARANBE AVE		TELEPHONE:	(310) 554-4824
CITY:	COMPTON	STATE: CA	ZIP CODE:	90220
CAPACITY: 6		CENSUS: 3	DATE:	01/16/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:59 AM
MET WITH:	Ashley Acosta, Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:36 PM

NARRATIVE

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On 1/16/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced annual required visit. LPA met with the Administrator, Ashley Acosta and explained the purpose of today’s visit. The purpose of today’s visit was to conduct the required annual inspection, using the new Care Tool. The facility is licensed approved for (6) ambulatory developmentally disabled clients (age 18-59). The census is currently 3.

Acosta Family Home III is a one-story structure located in a residential neighborhood. The facility consists of (4) bedrooms, (3) bathrooms, living room, kitchen, dining area and a laundry room and attached garage. Facility maintains all required posting throughout the facility.

LPA conducted a records review of (3) client records, (6) staff records, and (3) client medications. All client & staff records were complete. LPA Shirley and Ashley walked throughout the facility and all common areas such as the living room and dining room were all observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature was adjusted to meet state requirement between 105 – 120 F.

LPA observed that there is ample seating and space for all clients. All walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. Smoke/ Carbon Monoxide detectors were operable. The last fire/emergency drill was conducted on 12/6/25. There is (1) charged fire extinguisher. Exterior areas are clean and clear of obstructions and hazards and there are no bodies of water present. The client’s P&I records were not available for review.

Deficiencies are being cited based on LPA observations and interviews conducted in accordance with the California Code of Regulations, Title 22, Divisions 6 chapter 1, see LIC 809D.

An exit interview was conducted, and a copy of this report was provided to the Administrator, Ashley Acosta.

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Felisa Shirley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2026

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 01/25/2026 08:48 PM - It Cannot Be Edited

Created By: Felisa Shirley On 01/16/2026 at 02:08 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 III	FACILITY NUMBER: 198602619
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80026(e)(A)

80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents (e) cash resources, personal property, and valuables of clients shall be separate and intact, and shall not be commingled with facility funds or petty cash. (A) Documentation of such transactions shall be maintained in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the Administrator did not comply with the section cited above in which current P&I records were not available for review, can pose as a personal right risk to persons in care.
	POC Due Date: 01/30/2026
	Plan of Correction
1 2 3 4	Please review regulation cited for this violation and submit copies of all records for P&I funds for current clients to LPA Felisa Shirley via fax 424-544-1016 or email to felisa.shirley@dss.ca.gov by POC due date of 1/30/26.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Stephanie Cifuentes
NAME OF LICENSING PROGRAM MANAGER:

	Felisa Shirley
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2026

LIC809 (FAS) - (06/04)

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