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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198203450
Report Date: 01/15/2025
Date Signed: 01/15/2025 04:49:30 PM

Document Has Been Signed on 01/15/2025 04:49 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 CARE IVFACILITY NUMBER:
198203450
ADMINISTRATOR/
DIRECTOR:		MAGPILE, MYLENEFACILITY TYPE:
740
ADDRESS:627 N. PAULINA AVE.TELEPHONE:
(310) 372-0674
CITY:REDONDO BEACHSTATE: CAZIP CODE:
90277
CAPACITY: 6CENSUS: 5DATE:
01/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:08 PM
MET WITH:Assistant Administrator Joy BlackTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On 01/15/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – Annual Inspection and met with Staff Joy Black.

Facility is licensed to serve licensed to serve six (6) non-ambulatory elderly residents ages 60 and above. Facility may accept or retain six (6) residents on hospice.

The one-story residential house consists of six (6) resident bedrooms, kitchen, dining area, living room, three (3) residents bathrooms, staff quarter (located in the back of the house), garage, washer/dryer located in garage, and backyard with a shaded patio, front landscape and yard was well maintained at time of visit.

Joy accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. Common areas were clean and clear of hazards, doorways were free of obstructions.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, hot water temperature properly measured at 113F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Continue to LIC809-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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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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 CARE IV
FACILITY NUMBER: 198203450
VISIT DATE: 01/15/2025
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LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in locked storage cabinet.

Five resident records were reviewed.

Due to insufficient time, an annual continuation is required. An exit interview was conducted and a copy of this report was discussed and left with the Assistant Administrator Joy Black

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC809 (FAS) - (06/04)
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