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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850094
Report Date: 07/16/2025
Date Signed: 09/25/2025 04:01:49 PM

Document Has Been Signed on 09/25/2025 04:01 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ANGEL'S GROUP HOMEFACILITY NUMBER:
405850094
ADMINISTRATOR/
DIRECTOR:		CHONG KIMFACILITY TYPE:
735
ADDRESS:2648 VINEYARD CIRCLETELEPHONE:
(805) 369-2394
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 4CENSUS: 4DATE:
07/16/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:59 PM
MET WITH:Backup Administrator - Ivan PalominosTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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On 7/16/2025 at 3:00pm Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to conduct a case management visit aligned with a complaint visit on the same day. LPA met with Backup Administrator Ivan Palominos and explained the purpose of the visit.

During a recent complaint investigation LPA noted during a record review and interviews that Client #1 (C1) missed a follow-up podiatrist appointment in April 2025 due to staff not referring to the physician visit summaries. LPA interview with Staff #1 (S1), who schedules all client medical appointments revealed they have access to but do not refer to the physician visit summaries provided by the physicians, stating the reports are usually posted to the website a few days after the appointment. LPA record review also revealed the most recent reappraisal dated 11/21/2024 does not mention C1’s foot care needs or their ongoing skin condition that causes C1 to be itchy. LPA interviews with staff revealed an updated reappraisal had not been completed as of 7/2/2025. LPA discussed with Backup Administrator and S1 the importance of reviewing all physician provided documentation/orders, updating reappraisals with each change of condition, and communicating this to the care staff.

In accordance with Title 22 Regulations, deficiencies were cited today.



Exit interview conducted, deficiencies cited on LIC809-D, report, and appeal rights given.
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2025
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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Document Has Been Signed on 09/25/2025 04:01 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 07/16/2025 at 04:15 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANGEL'S GROUP HOME
FACILITY NUMBER: 405850094

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/30/2025
Section Cited
CCR
80078(a)

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Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement is not met as evidenced by:
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S1 states they recieve an email every time the physician summaries are available in the portal. They have started looking at every summary. S1 and Administrator Junsik Kim will create a protocol to access and check the reports when they're available. Administrator email this protocol to LPA on or before 7/30/2025.
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Based on interviews and record review, the licensee did not comply with the section cited above when they allowed C1 to miss a follow-up podiatrist appointment which posed a potential health and safety risk to clients in care.
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Type B
07/30/2025
Section Cited
CCR85068.3(a)

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Modifications to Needs and Services Plan (a)The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary... to document significant occurrences that result in changes in the client's physical...functioning.
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Backup Adminstrator and S1 will update C1's Needs and Services Plan and email the updated plan to LPA on of before 7/30/2025. Administrator Junsik Kim and LPA will discuss additional plan's to ensure ongoing updates to client Needs and Services Plan's when Junsik returns from vacation.
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This requirement is not met as evidenced by:
Based on interviews and record review, the licensee did not comply with the section cited above when they did not ensure C1’s Needs and Services Plan were updated addressing the ongoing
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skin condition and foot care needs which poses a potential health and safety risk to clients in care.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Garrett Haner-Tomasko
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2025


LIC809 (FAS) - (06/04)
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