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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850381
Report Date: 08/20/2025
Date Signed: 08/20/2025 05:17:53 PM

Document Has Been Signed on 08/20/2025 05:17 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 HOME LLCFACILITY NUMBER:
405850381
ADMINISTRATOR/
DIRECTOR:		JUNSIK KIMFACILITY TYPE:
735
ADDRESS:1486 COUNTRY CLUB DRTELEPHONE:
(805) 286-4239
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 4CENSUS: 3DATE:
08/20/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Administrator - Junsik KimTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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At 1:40pm on 08/20/2025, Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced to the facility to conduct a case management visit along with Tri-Counties Regional Center (TCRC). LPA met with Administrator Junsik Kim and announced the reason for the visit.

On 8/18/2025, Licensing received an incident report from this facility regarding an incident that happened on 8/15/2025. Review of the incident report and staff interview revealed Client #1 (C1) became upset at the facility possibly due to not being able to care for their financial matters at the bank earlier in the day. At around 4:15pm C1 started to do their usual behaviors; yelling, cussing, calling staff vulgar names, banging on the walls, kicking the walls, throwing things and following Staff #1 (S1) around while screaming and yelling at them. S1 contacted the Licensee, the Licensee attempted to talk to C1 over the phone and at one point reminded C1 they may need to call 911 or the crisis unit if anyone felt threatened by C1’s behavior. C1 began to yell and curse at the Licensee. The Licensee privately asked S1 over the phone to try one more time to address C1’s behaviors before calling 911 or the crisis unit. C1 told S1 they did not want to stay at the facility anymore and asked to be taken back to the homeless shelter they were at before moving into the facility. S1 called the Licensee again, the Licensee asked C1 if they were sure they wanted to return to the homeless shelter, and C1 said “yes”. The Licensee asked S1 to pack-up C1’s belongings, C1 assisted in packing, S1 asked C1 again if they were sure this is what they wanted to do and the incident report states C1 said “Yes! I’m finally going to get away from all of you bitches! You guys are a bunch of bitches and I hate you!” The administrator Junsik Kim arrived at the facility and attempted to take C1 to a couple of different homeless shelters in Atascadero and Paso Robles but they were full. S1 called homeless shelters for availability.

(Continued on LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2025
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 4
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANGEL'S GROUP HOME LLC
FACILITY NUMBER: 405850381
VISIT DATE: 08/20/2025
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At around 6pm the Administrator dropped C1 off at the homeless shelter located in San Luis Obispo C1 had resided in before coming to this facility.

The incident report states a 60-day eviction notice was issued to C1 prior to this incident. Record review reveals the eviction notice was not submitted to the Department per Title 22 regulations. S1 and the Administrator Junsik state they were not aware an eviction notice needed to be submitted to the Department. TCRC had a copy of the eviction notice submitted to them dated 07/28/2025. The eviction notice states the reason for the decision to evict is for disruptive out bursts and behaviors that C1 has been having. These episodes have caused their other residents a lot of stress, anxiety and they have made it very clear to the licensee that they no longer feel safe and want to move to a different home. File review reveals prior to the incident on 8/15/2025 the facility has not reported to the Department any incident that threatens the physical or emotional health or safety of C1, Client #2, Client #3, or Client #4, per Title 22 regulations. S1 and the Administrator Junsik state they were not aware incident reports needed to be submitted to the Department when an incident occurs that threatens the physical and emotional health and safety of any client.

LPA may return at a later date to further address this incident.

Exit interview, deficiencies cited on LIC809-D, report signed, report and appeal rights provided to Administrator.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/20/2025 05:17 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 08/20/2025 at 04:32 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 LLC
FACILITY NUMBER: 405850381

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/03/2025
Section Cited
CCR
80068.5(e)

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Eviction Procedures (e) The licensee shall mail or fax to the Department a copy of the 30-day written notice in accordance with (a) above within five days of giving the notice to the client. This requirement was not met as evidenced by:
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Administrator states they will train the lead staff, such as S1, and backup Administrators on this regulation and the other eviction procedure regulations. Administrator will email LPA training documents, signed staff roster and a statement of understanding of this regulation on or before 9/3/202025.
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Based on interview and record review, the licensee did not submit to the department within five days of giving the eviiction notice to C1 on 07/28/2025 as required which poses a potential health, safety, and personal rights risk to persons in care.
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Type B
09/03/2025
Section Cited
CCR80061(b)(1)(E)

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Reporting Requirements (b)Upon the occurrence…a report shall be made to the licensing agency within the agency's next working day…In addition, a written report…shall be submitted to the licensing agency within seven days…(1)Events reported shall include the following:
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Administrator states they will train the lead staff, such as S1, and backup Administrators on this regulation and all reporting requirements in 80061 and email LPA training documents, signed staff roster and a statement of understanding of this regulation on or before 9/3/2025.
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Any unusual incident…which threatens the physical or emotional health or safety of any client. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not report to the Department incidents that threaten the physical or emotional health as mentioned in the eviction notice for C1 or safety which poses a potential health, safety,
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and personal rights risk to persons 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: 08/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2025


LIC809 (FAS) - (06/04)
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