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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607882
Report Date: 06/05/2025
Date Signed: 06/05/2025 03:02:32 PM

Document Has Been Signed on 06/05/2025 03:02 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ANGEL ASSISTED LIVING SERVICESFACILITY NUMBER:
197607882
ADMINISTRATOR/
DIRECTOR:		ELVIRA CLAVERIAFACILITY TYPE:
740
ADDRESS:4401 234TH PLACETELEPHONE:
(310) 373-9275
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY: 6CENSUS: 4DATE:
06/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 06/05/2025, Licensing Program Analyst (LPA), Wendy Gibbs conducted an unannounced annual visit using the CARE Inspection Tool. LPA met with lead caregiver Elvira Brondial, and the purpose of today’s visit was explained. LPA was granted entry into the facility. We were later joined by Licensee, Leia Joaquin. The facility is licensed to serve six (6) bedridden elderly adults ages 60 and above, with an approved hospice waiver for one (1) resident.
Physical Plant/Structure The facility is a single-story structure located in a residential neighborhood. It consists of six (6) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, living room, dining room, kitchen, attached garage, and an outside area. During the inspection, LPA observed all walkways around the outside of the facility were observed clean, clear, and free of debris, obstructions, and hazards. LPA observed a table with an umbrella and chairs for residents use. LPA did not observe any bodies of water on the premises.
Bedrooms LPA inspected all resident bedrooms. LPA observed all bedrooms were clean and in good repair. LPA observed all rooms have the required furniture including a bed, dress, nightstand, chair, and ample storage space for resident’s personal belongings. LPA observed the beds have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. LPA observed an additional supply of linens, in good repair, stored in a closet in the hallway. All bedrooms were observed with ample lighting.
Bathrooms LPA inspected all bathrooms and fount them to meet Title 22 regulations and were operable. LPA observed the showers are clean and free mold and mildew. LPA observed resident hygiene boxes stored in a closet in the hallway. LPA observed an additional supply of hygiene products stored in the closet in the hallway. LPA observed an ample supply of towels, hand towels, and wash cloths. LPA observed safety handrails are secured. LPA observed an ample supply of incontinent products and supplies. LPA
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2025
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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ANGEL ASSISTED LIVING SERVICES
FACILITY NUMBER: 197607882
VISIT DATE: 06/05/2025
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observed cleaning supplies secured in a locked cabinets under the sinks. The water temperature measured 106.8-degrees, 107.2-degrees, and 114.3-degrees Fahrenheit.
Kitchen LPA inspected the kitchen and observed it to be clean and sanitary. LPA observed all appliances are operable and in good repair. LPA observed an ample supply of dishware, cookware, and cutleries in good repair. LPA observed a 3-day supply of perishable foods, and a 7-day supply of nonperishable foods properly stored, labeled, and dated. LPA observed cleaning supplies and toxins secured in the locked cabinet under the kitchen sink and are inaccessible to residents. The water temperature measured 116.2-degrees Fahrenheit.
Common Areas LPA observed in the living room there are four (4) recliners and two (2) chairs available for resident use. LPA observed games and activities available for residents. The dining room has a large table with chairs to accommodate all residents. LPA observed the facility was appropriately furnished during time of visit. LPA did observe a screened fireplace inaccessible to residents. All walkways and hallways inside the facility were observed clean, clear, and free of obstructions and hazards. The facility was maintained at a comfortable temperature of 74-degrees Fahrenheit.
Files LPA reviewed the file for four (4) residents and found they contained the required documents. LPA reviewed the Administrator and three (3) staff files and found they contained the required documents, training, and certifications. The Administrator Certificate is valid till 07/19/2025. LPA informed Licensee Licensing Fees were overdue. LPA provided the PIN to pay fees online was provided the confirmation of payment.
Medications LPA observed medications secured in a locked cabinet in the kitchen and are inaccessible to residents. LPA observed medications in their original packaging. LPA reviewed the medication and Medication Administration Record (MAR) for four (4) residents and observed four (4) out of four (4) resident’s medications are consistent with properly documented records.
Safety LPA observed smoke and carbon monoxide detectors are operable. LPA observed two (2) fully charged fire extinguishers lasted serviced on 03/29/2025. The last fire prevention was conducted by the Torrance Fire Department on 08/23/2024. The last emergency drill was conducted 06/02/2025. LPA reviewed the facility’s liability insurance through Acord that is valid till 02/02/2025. LPA reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E) that was last updated on 06/04/2025. LPA inspected the First Aid kit and observed it contained the required items and a current manual. The facility has an operational landline telephone. All exits are marked with an EXIT sign. All doors have an alarm that chimes when a door exiting the facility is opened. LPA observed all required postings
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ANGEL ASSISTED LIVING SERVICES
FACILITY NUMBER: 197607882
VISIT DATE: 06/05/2025
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posted in the hallway at the entrance of the facility.
Infection Control During the visit, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the entrance of the facility that has a visitor log, hand sanitizer, thermometer, and masks. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). LPA observed all required infection control signs were posted in the facility.

During today’s visit, LPA did not observe or cite any deficiencies.

An exit interview was conducted with Licensee, Leia Joaquin, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC809 (FAS) - (06/04)
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