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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002275
Report Date: 05/06/2026
Date Signed: 05/06/2026 04:53:21 PM

Document Has Been Signed on 05/06/2026 04:53 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ANGELS HOMEFACILITY NUMBER:
306002275
ADMINISTRATOR/
DIRECTOR:		RAFAEL A. TORRESFACILITY TYPE:
735
ADDRESS:12061 LORALEEN STREETTELEPHONE:
(714) 537-3413
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 6CENSUS: 2DATE:
05/06/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Cecilia TimanTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced Annual Required inspection visit on this date. LPA Tea was greeted and granted entry into the facility by Lead DSP Staff Cecilia Timan, who was informed of the purpose of the visit. The facility is licensed to serve six ambulatory clients. At the time of today’s visit, there were two clients residing at the facility.

LPA reviewed two client files and two staff files. Files reviewed contained the required documentation. The Administrator Certificate for Administrator Rafael Torres expired on April 23, 2026. The administrator reported that all required course work has been completed and submitted and is currently pending renewal approval.

LPA Tea, accompanied by staff, conducted a tour of the facility. The physical plant, food service, medication storage, and first aid supplies were inspected. The facility is a single-story home consisting of four client bedrooms, one staff room, two-and-one-half bathrooms, a kitchen, dining room, living room, and attached garage. LPA observed smoke detectors and carbon monoxide detectors located throughout the common areas and bedrooms; however, several devices were found to be non-operational. Client bedrooms were observed to contain the required furniture, adequate bedding, and sufficient closet and drawer space to comfortably accommodate clients in care.

Client bathrooms were inspected. Toilets and faucets were functioning properly, grab bars were secure, and showers were free from mold and mildew. Water temperature measured approximately 105.1 degrees Fahrenheit. Towels, toiletries, and personal hygiene supplies were adequately stocked at the time of inspection. Common areas were observed to be clean, sanitary, and free from obstructions or safety hazards. The first aid kit was inspected and found to contain all required items.


(Continuation of annual report on LIC809C)
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Michael Tea
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
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 05/06/2026 04:53 PM - It Cannot Be Edited


Created By: Michael Tea On 05/06/2026 at 04:08 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ANGELS HOME
FACILITY NUMBER: 306002275

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation during the physical plant tour some of the smoke detectors were not working. This poses as a potential health and safety risk to clients in care.
POC Due Date: 06/03/2026
Plan of Correction
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Facility will replace smoke detectors and provide LPA proof by POC due date.
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 LPA's observation during the physical plant tour one of the kitchen stove burners were not working. There is also a rusty part exposed in the main bathroom. This poses as a potential health and safety risk to clients in care.
POC Due Date: 07/01/2026
Plan of Correction
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Facility fix gas burners or replace stove and fix the bathroom shower and provide proof by POC due date to LPA
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Michael Tea
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2026


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 05/06/2026 04:53 PM - It Cannot Be Edited


Created By: Michael Tea On 05/06/2026 at 04:08 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ANGELS HOME
FACILITY NUMBER: 306002275

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation during the physical plant tour the back side gate on the right side of the house is locked with a chained lock. Also there are rocks in front the garage door. This poses as a potential health and safety risk to clients in care.
POC Due Date: 06/03/2026
Plan of Correction
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Facility will remove lock and make side gates accessible especially in case of amergency. Will provide proof to LPA by POC due date.
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, cleaning toxins were not locked underneath the kitchen sink. This poses as a potential health and safety risk to clients in care.
POC Due Date: 06/03/2026
Plan of Correction
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Facility will secure cleaning toxins securely and provide proof to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Michael Tea
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2026


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 05/06/2026 04:53 PM - It Cannot Be Edited


Created By: Michael Tea On 05/06/2026 at 04:08 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ANGELS HOME
FACILITY NUMBER: 306002275

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of records, LPA did not observed any health screening for care staff. This poses as a potential health and safety risk to clients in care.
POC Due Date: 06/03/2026
Plan of Correction
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Facility will complete health screening and show proof of completion to LPA by POC due date.
Type B
Section Cited
CCR
80070(b)(8)
Client Records
(b) Each record must contain information including, but not limited to, the following: (8) Medical assessment, including ambulatory status, as specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the LPA's review of records, one of the clients physician report says "non-ambulatory" when it should be "ambulatory" this poses as a potential health and safety risk to clients in care.
POC Due Date: 06/03/2026
Plan of Correction
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Facility will provide corrected physician's report with correct ambulatory status by POC due date to LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Michael Tea
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2026


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 05/06/2026 04:53 PM - It Cannot Be Edited


Created By: Michael Tea On 05/06/2026 at 04:08 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ANGELS HOME
FACILITY NUMBER: 306002275

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of records there were no disaster drills conducted in the last quarter of year. Last drill was conducted 12/05/2025. This poses as a potential health and safety risk to clients in care.
POC Due Date: 06/03/2026
Plan of Correction
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Facility will provide proof of a completed fire drill for the quarter to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Michael Tea
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2026


LIC809 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ANGELS HOME
FACILITY NUMBER: 306002275
VISIT DATE: 05/06/2026
NARRATIVE
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The kitchen was inspected, and both perishable and non-perishable food supplies were observed to be adequately stocked. Sharps were stored in the staff room and made inaccessible to clients in care. LPA observed toxic cleaning substances stored underneath the kitchen sink and not secured. Fire extinguishers throughout the facility were fully charged. The last documented fire drill was conducted on December 5, 2025, indicating fire drills are overdue for the current quarter. LPA also observed that one burner on the kitchen stove was not functioning properly.

LPA toured the exterior grounds of the facility and observed adequate shaded seating available in the front yard area. One side gate was observed to be locked. Emergency food and water supplies were observed in the kitchen and laundry areas. Staff reported that activities are provided based on each client’s individual preferences and interests.

LPA reviewed medication storage and administration procedures. Medications were stored in a locked kitchen cabinet and were being administered in accordance with physician’s orders. Personal and Incidental (P&I) funds were reviewed and found to be maintained in compliance with departmental requirements.

LPA interviewed staff present regarding the care and supervision provided at the facility. LPA was unable to interview clients during today’s visit, as the clients returned to the facility at the conclusion of the inspection.

The following deficiencies are being cited in accordance with Title 22, Division 6, of the California Code of Regulations.

This report was reviewed with Administrator Rafael Torres via telephone. Copies of LIC 809, LIC 809-C, LIC 858, LIC 859, LIC 809-D, and Appeal Rights were provided to the facility upon exit.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Michael Tea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2026
LIC809 (FAS) - (06/04)
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