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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304311650
Report Date: 08/07/2025
Date Signed: 08/07/2025 12:29:25 PM

Document Has Been Signed on 08/07/2025 12:29 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:PEREZ, ANGELLUZFACILITY NUMBER:
304311650
ADMINISTRATOR/
DIRECTOR:		PEREZ, ANGELLUZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 614-1709
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
08/07/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Licensee, Angelluz PerezTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Cynthia Sun conducted an unannounced follow-up case management inspection in response to a self-report Unusual Incident dated 05/23/25. LPA met with Licensee Angelluz Perez and informed the purpose of today’s case management initiated on 05/23/2025. A review of staff criminal clearance records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

The Regional office received an Unusual Incident Report on 5/23/2025. It was reported by Licensee, Angelus Perez. According to Licensee, Angelluz on 5/21/25, approximately 9:00 PM-9:30 PM, Child #1 (C1’s) parent #1 (P1) texted licensee then P1 called licensee. P1 stated that C1 parent #2 (P2) sent P1 pictures where C1 had bite marks on right side of leg and bruises on both legs, not sure if on right arm too. P1 asked the licensee what happened. The licensee explained to P1 that C1 left the facility without bites and bruises. P1 stated P1 was afraid P2 might hurt C1 because in the past P2 bit P1.

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NAME OF LICENSING PROGRAM MANAGER: Thuy Ho
NAME OF LICENSING PROGRAM ANALYST: Cynthia Sun
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2025
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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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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: PEREZ, ANGELLUZ
FACILITY NUMBER: 304311650
VISIT DATE: 08/07/2025
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On 05/27/2025, LPA interviewed Staff #2 (S2) who stated “Maybe this happened on a Wednesday (could not remember date), I am not sure. S1 and I were with the children. C1 arrived past 11:00 AM, P2 brought C1 to the facility. I received C1 and closed the door when C1’s P2 left. I brought the C1 into the facility, fed C1, C1 played a little, and then I changed C1’s diaper and then I laid C1 to rest. Around 3:00 PM, C1 woke up from nap, I changed C1’s diaper, I told S1 all children’s diapers were changed. I moved the children to eat snack. Children were eating snack and watching T.V. S1 changed C1’s diaper again. When P2 picked up, I gave C1 to P2 and P2 and C1 left the facility. On 5/21/25, 9:30 PM, S1 called me, S1 said S1 got a call from P1 stating that C1 had bites. When we had C1, C1 did not have bites or bruises. None”. LPA asked S2 if S2 saw bruises or bites on C1 before C1 was picked up by P2. S2 stated “No, C1 did not have any bruises or bites when C1 was here at facility. A baby tried to bite C1 he didn't bite C1 but I still informed C1’s parent. LPA asked staff if they speak to parents when they arrive to facility about any bruises or bites. S2 stated “Yes, our policy is that we tell parents if we notice bruises immediately.” S1 stated I explained to P2 that we check child at facility and child did not ha bruises or bites. I told P2 we checked C1 when we changed C1’s diaper. I personally checked C1. I should have taken a photograph of C1”.

LPA interviewed P1 stated “I think this happened at P2’s The same thing happened last year, C1 was an infant, C1 got bruises, last years, I went to the Buena Police Department and filed a report because C1 had bruises. P1 stated P1 does not believe C1 was bitten at facility. P1 believes P2 bit C1. P1 stated P2 lives alone and there is no one else in P2’s home who could have bitten C1. P1 stated P1 placed C1 in a different childcare facility on 6/2/25, but now C1 is not attending facility because C1 was bitten again (20 times) and child was removed from P1’s home. P1 stated neither P1 or P2 are keeping C1 at home. P1 stated C1 is now at Orangewood Shelter until they go to court.

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NAME OF LICENSING PROGRAM MANAGER: Thuy Ho
NAME OF LICENSING PROGRAM ANALYST: Cynthia Sun
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: PEREZ, ANGELLUZ
FACILITY NUMBER: 304311650
VISIT DATE: 08/07/2025
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LPA requested the Buena Park Report on 7/22/25 and 7/16/25. The Buena Park report stated based on information, it’s unknown who caused injuries to C1 or how they occurred.

Based on LPA’s interviews and record review, it was determined the facility was in compliance with regulations and no deficiency was observed.

Exit interview conducted and report was reviewed with Licensee Notice of Site Visit was posted and must remain posted for 30 days. Failure to comply with the posting requirements shall result in an immediate civil penalty of $100.

Appeal Rights were explained. The licensee was provided with a copy of the appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above.

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END OF REPORT

NAME OF LICENSING PROGRAM MANAGER: Thuy Ho
NAME OF LICENSING PROGRAM ANALYST: Cynthia Sun
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
LIC809 (FAS) - (06/04)
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