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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607882
Report Date: 07/16/2021
Date Signed: 07/19/2021 11:00:43 AM

Document Has Been Signed on 07/19/2021 11:00 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) 373-9275
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY: 6CENSUS: 5DATE:
07/16/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Justin Vicerra - AdministratorTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Don Senaha conducted an unannounced case management visit to Angel Assisted Living Services on 07/16/2021. LPA met with Administrator Justin Vicerra and explained the purpose of today’s visit is to issue a citation

During the annual investigation conducted on 06/18/2021, LPA Senaha reviewed facility files and due to time constraints was unable to issue a citation at that time. LPA Senaha discovered the following: Staff (S1) did not have a Social Security number on file. Staff (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 the report and appeal rights were given to the Administrator.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2021
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 2
Document Has Been Signed on 07/19/2021 11:00 AM - It Cannot Be Edited


Created By: Don Senaha On 07/16/2021 at 10:28 AM
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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ANGEL ASSISTED LIVING SERVICES
FACILITY NUMBER: 197607882

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/27/2021
Section Cited
CCR
87412(a)(2)

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Personnel Records
The licensee shall ensure that personnel records are maintained on the...and each employee. Each personnel record shall contain the following information:…Social Security number…as specified in Section 87412 (a)(2).
This requirement is not met as evidenced by:
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Licensee shall ensure all staff have a Social Security number on file. Licensee reviewed title 22 regulations, Personnel Records 87412 and signed paper acknowledging review of section. Administrator to supply copy of Social Security number prior to 07/27/2021
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Based on LPA observation and records review staff (S1) did not have a Social Security number on file. This poses a potential 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: 07/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2021


LIC809 (FAS) - (06/04)
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