<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881415
Report Date: 07/08/2026
Date Signed: 07/08/2026 05:46:05 PM

Document Has Been Signed on 07/08/2026 05:46 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ANGELICA'S HOME, INC.FACILITY NUMBER:
331881415
ADMINISTRATOR/
DIRECTOR:		OOSTING, ANGELICAFACILITY TYPE:
740
ADDRESS:31916 CORTE POSITASTELEPHONE:
(321) 432-8883
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY: 6CENSUS: 6DATE:
07/08/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Angelica Oosting, LicenseeTIME VISIT/
INSPECTION COMPLETED:
06:00 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
Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry by Angelica Oosting. LPA began inspection with introduction, visit purpose and provided the facility with LPA identification and business card.

Resident record review began- Six (6) records were reviewed. LPA reviewed for admission agreement-1 amended, medical assessment and TB test results, consent forms-missing, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records-6 missing, safeguard for personal property/valuables, and personal rights notification. This facility is not meeting documentation requirements. TSP will be requested and mandated for the facility.

Employee records review began- Four (4) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance-1 does not have, 1 is not associated, personnel/job application, health screening-2 missing and TB test results, criminal record statement, training verification-(4) requested and was not able to be viewed for 2026, and current administrator certification. CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and current 03/12/2027. Corporation or LLC is active and in good standing. TSP will be requested and mandatory for the facility.




(Continued on LIC809, Page 2)
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Yolanda Delgado
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2026
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 5
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)
Page: 2 of 5
Document Has Been Signed on 07/08/2026 05:46 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 07/08/2026 at 04:44 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ANGELICA'S HOME, INC.
FACILITY NUMBER: 331881415

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in S1 did not have a cleared criminal background clearance, not associated to the facility, S2 was not associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2026
Plan of Correction
1
2
3
4
Licensee will have S1 submit fingerprints to CCLD, have S2 associated to the facility and submit proof via email to LPA by POC Due date. S1 will be placed back on the schedule when a cleared criminal background is received and is assocated to the facility.
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) Licensees that lock exterior doors or perimeter fence gates shall meet the following initial and continuing requirements: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or perimeter fence gates and that facility staff on all shifts have access to, and know how to use, equipment needed to unlock exterior doors or perimeter fence gates.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in a Master lock observed on the perimeter gate and staff is unable to locate key to unlock and there is not an approved fire clearance for locked exterior perimeter fence gate which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2026
Plan of Correction
1
2
3
4
Licensee will remove the Master lock from the gate and email a picture 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.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Yolanda Delgado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2026


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/08/2026 05:46 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 07/08/2026 at 04:53 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ANGELICA'S HOME, INC.
FACILITY NUMBER: 331881415

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
87203
FIRE SAFETY: All facilities shall be mainained in comformity with the regulations adopted by the State Fire Marshall for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation, interview and record review)], the licensee did not comply with the section cited above in resident room #1 there was a white metal door guard screwed into the door frame that secures the door from opening and it is a shared room that has a bedridden and hospice living in the room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2026
Plan of Correction
1
2
3
4
Licensee will remove the metal door guard from #1 and email a picture to LPA by POC due date and ensure no devices are installed or in use for residents rooms, exit door/areas without having an approved fire clearance that states such.
Type A
Section Cited
CCR
87212(A)
Emergency Diaster Plan:
(A) Fire Safety Plan

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in fire extinger was observed and could not be verified to be operational as it did not have a tag to verify when it was last tested or replaced which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2026
Plan of Correction
1
2
3
4
Licensee will obtain a fire extinguisher for the facility and ensure fire extinguisher is replaced annually and email a picture or receipt 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.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Yolanda Delgado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ANGELICA'S HOME, INC.
FACILITY NUMBER: 331881415
VISIT DATE: 07/08/2026
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
26
27
28
29
30
31
32
(Continued from LIC809, Page 1)

Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside-1 white metal door guard observed in Resident room #1 that prevents exiting the room. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 112.9 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in the garage. All outdoor and indoor passageways are free of obstruction except a Master lock was observed on the hook of the perimeter fence gate and was unable to be unlocked due to key not being available to unlock. A locked area is provided for medications and sharp objects. LPA verified there is a telephone working at this location.

Food Service- Food supply meets the of one week supply of nonperishable and 2-day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized.

LPA made observations throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations in which it is not at this time. The facility has exceeded its capacity limitation, and the structure has changed according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguisher was not able to be verified as there was no tag or receipts when it was last tested or replaced. The facility is conducting emergency disaster drills. Corporation is active and in good standing.

Based on the information received during this visit today, there are four (4) deficiencies that are being cited with Civil Penalties for a total of $2000 per Title 22, Division 6 of The California Code of Regulations.

This report, LIC 809D, LIC421BG, LIC421M, Appeal Rights was reviewed with Angelica Oosting and copies provided at the time of the exit interview.

*LPA was away from the facility from 12:00 PM-1:00 PM
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Yolanda Delgado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2026
LIC809 (FAS) - (06/04)
Page: 5 of 5