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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198203450
Report Date: 01/16/2025
Date Signed: 01/16/2025 02:17:09 PM

Document Has Been Signed on 01/16/2025 02:17 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:
01/16/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:33 AM
MET WITH:Administrator Mylene MagpileTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 01/16/2025, LPA Regina Cloyd conducted an unannounced annual continuation and met with Administrator Mylene Magpile.

First Aid kit was available. Two fire extinguishers, last serviced March 20, 2024 was observed in the kitchen and garage area. Staff tested carbon monoxide detectors and smoke detector located near the kitchen and living room. Both devices were functional.

On 01/15/25, five resident records were reviewed and, 4 out of 5 resident records had medical assessments. Two residents’ medication was reviewed. Five out of five staff records had current first aid certificates and had required criminal record clearances or criminal record exemptions.

LPA reviewed the facility's emergency disaster plan and infection control plan.

Deficiencies are being cited based on resident record review. On 01/15/25, LPA did not observe documentation for an annual routine visit or virtual visit for Resident #3 (R3). See LIC809-D.

An exit interview was conducted, technical assistance provided, and plans of correction were developed. A copy of this report and appeals was discussed and left with the Administrator Mylene Magpile.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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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Document Has Been Signed on 01/16/2025 02:17 PM - It Cannot Be Edited


Created By: Regina Cloyd On 01/16/2025 at 02:01 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ANGEL CARE IV
FACILITY NUMBER: 198203450

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)(1)
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of five residents which poses/posed a potential health risk to persons in care. On 01/15/24, LPA did not observe an annual routine visit document for Resident #3 (R3).
POC Due Date: 01/28/2025
Plan of Correction
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The Administrator will email R3's annual routine documentation by the POC due date to regina.cloyd@dss.ca.gov.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Ulysses Coronel
LICENSING EVALUATOR NAME:Regina Cloyd
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
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