405850404-7-28-2026-29-AS-GHTO-DWESKF-20260728135642

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850404
Report Date: 07/28/2026
Date Signed: 07/28/2026 01:57:09 PM

Document Has Been Signed on 07/28/2026 01:57 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		FACILITY NUMBER:	405850404
ADMINISTRATOR/ DIRECTOR:	JUNSIK KIM		FACILITY TYPE:	735
ADDRESS:	189 RIVERBANK LANE		TELEPHONE:	(805) 286-4584
CITY:	PASO ROBLES	STATE: CA	ZIP CODE:	93446
CAPACITY: 4		CENSUS: 3	DATE:	07/28/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Backup Administrator - Victoria Hong		TIME VISIT/ INSPECTION COMPLETED:	02:15 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	At 8:00am, on 7/28/2026, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct the annual facility inspection. LPA met with Staff #1 (S1) upon arriving to the facility, announced who he was and the reason for the visit. S1 stated they were the only staff present at the time and notified Administrator Junsik Kim who arrived at approximately 8:30am. The Administrator left at approximately 9:15am to tend to other tasks and backup Administrator Victoria Hong continued the visit with the LPA. Administrator and LPA conducted a full tour of the facility. This facility is a single story residential home with four single occupancy client bedrooms and one full shared bathroom. A staff bedroom is located at the end of the hallway and has an en-suite bathroom. There is a living room with dining space, a kitchen and office area. LPA noted a fireplace in the living that does not appear to be used and has accordion glass doors for client safety. Access to the laundry room and garage is through a locked door for client safety. LPA noted that the backyard has seating and shade for clients and visitors. LPA noted fresh fruit and snacks in the kitchen for clients to enjoy freely. The facility has battery operated smoke detectors in each bedroom and hallway leading to bedrooms that are all working, the carbon monoxide detector is in the office area near the kitchen and functioning normally. LPA observed a fire extinguisher near the kitchen that was tagged current and in the green compression range, serviced on 4/15/2026. LPA tested facility hot water at 111.6°F, within regulation temperatures 105-120°F. LPA observed at least 2-days of perishable and at least 7-days of nonperishable foods. LPA noted that the facility is clean with no obstructions in hallways, doorways or exits. (Continued on LIC421BG)

Kelly Burley
Garrett Haner-Tomasko
	DATE: 07/28/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026

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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Document Has Been Signed on 07/28/2026 01:57 PM - It Cannot Be Edited

Created By: Garrett Haner-Tomasko On 07/28/2026 at 12:40 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: 405850404
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(f)

Health-Related Services

(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 3 staff who care for clients and do not have first aid training which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/11/2026
	Plan of Correction
1 2 3 4	Backup Administrator states they will have all staff take first aid training and email LPA certificates of completion on or before 8/11/2026.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 07/28/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANGEL'S GROUP HOME	FACILITY NUMBER: 405850404
	VISIT DATE: 07/28/2026

NARRATIVE

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Medications are locked in a cabinet. LPA conducted a medication audit and reviewed the facilities Centrally Stored Medication Records. Staff and client files are locked in filing cabinets. LPA conducted a staff and resident file review. Upon review of S1's record it was discovered that S1 is not cleared to work at the facility or any of the Licensee's facilities. S1 is the primary live in staff at this facility and was recently hired. LPA also noted during staff file review that two (2) of the three (3) staff that provide direct care are not trained in first aid as required by regulation.

LPA and backup Administrator conducted a review of the annual care tool modules.

Exit interview conducted, deficiencies cited on LIC809-D pages, a civil penalty for $100 per day for a maximum of 5 days in the amount of $500 each for criminal record clearance violation is being assessed on the attached LIC421BC, appeal rights and report provided to the backup Administrator.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/28/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026

LIC809 (FAS) - (06/04)

Page: 6 of 6

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 07/28/2026 01:57 PM - It Cannot Be Edited

Created By: Garrett Haner-Tomasko On 07/28/2026 at 12:40 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: 405850404
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1522(c)(1)

General Provisions

(1) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification pursuant to subdivision (g) of this section or Section 1522.7 from the State Department of Social Services prior to employment, residence, or initial presence in the facility.  This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above when S1 was noted to work and reside at the facility and is not cleared which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/29/2026
	Plan of Correction
1 2 3 4	S1 was sent for fingerprint clearance during LPA visit. Backup Administrator states S1 will not return to the facility until they are cleared and cleared staff will cover until S1 can return to the facility. They also state a meeting is scheduled for this evening to review this deficiency with all administration and they will email LPA meeting minutes and roster of attendees on or before 7/31/2026.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 07/28/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026

LIC809 (FAS) - (06/04)

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