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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607882
Report Date: 06/18/2021
Date Signed: 07/19/2021 10:58:42 AM

Document Has Been Signed on 07/19/2021 10:58 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ANGEL ASSISTED LIVING SERVICESFACILITY NUMBER:
197607882
ADMINISTRATOR:ELVIRA CLAVERIAFACILITY TYPE:
740
ADDRESS:4401 234TH PLACETELEPHONE:
(310) 227-9314
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY: 6CENSUS: 6DATE:
06/18/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Justin VicerraTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Don Senaha conducted an unannounced case management visit to Angel Assisted Living Services. LPA met with Administrator Justin Vicerra and explained the purpose of today’s visit is to issue a deficiency.

During annual investigation, LPA Senaha reviewed facility files and staff associations. LPA Senaha discovered the following: Staff 1 (S1) is not fingerprint cleared or associated to the facility. Civil Penalties will be assessed.

Staff 1 (S1) started working at the facility per LIC 501 on 5/13/2021.

Deficiencies cited under California Code of Regulations Title 22, see LIC 809D.

An exit interview was conducted with Justin Vicerra, and appeal rights were discussed with staff.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2021
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 07/19/2021 10:59 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/21/2021 10:00 AM


Created By: Don Senaha On 06/18/2021 at 02:33 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ANGEL ASSISTED LIVING SERVICES
FACILITY NUMBER: 197607882

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/19/2021
Section Cited
CCR
87355(e)(1)

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Criminal Record Clearance
All individuals subject to a criminal record review...shall prior to working...in a licensed facility: Request and be approved for a transfer of a criminal record exemption, as specified in Section 87355(e)(1).
This requirement is not met as evidenced by:
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Licensee shall ensure all staff are fingerprint cleared and associated to facility prior to start of employment. Licensee will review title 22 regulations and submit statement acknowledging review to CCL.
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Based on LPA observation of records staff 1(S1) is not fingerprint cleared or associated to the facility. This poses an immediate health and safety risk to clients in care.
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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.
SUPERVISOR'S NAME:Eva M Alvarez
LICENSING EVALUATOR NAME:Don Senaha
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2021


LIC809 (FAS) - (06/04)
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