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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320262
Report Date: 04/17/2026
Date Signed: 04/20/2026 08:51:58 AM

Document Has Been Signed on 04/20/2026 08:51 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:FLORESMA GUEST HOMEFACILITY NUMBER:
198320262
ADMINISTRATOR/
DIRECTOR:
SERRANO, CARLFACILITY TYPE:
740
ADDRESS:1812 E. HARDWICK AVETELEPHONE:
(562) 895-2418
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: 6CENSUS: 3DATE:
04/17/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Caregiver Arturo YangcoTIME VISIT/
INSPECTION COMPLETED:
03:33 PM
NARRATIVE
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On 04/17/26, Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Arturo Yangco as the purpose of the visit was explained. The facility is licensed to serve (6) non ambulatory residents 60 and above, there is an approved hospice waiver approved for (4). Liability Insurance is active (exp: on 4/29/2026), facility fees are due (Balance: $495, due date: 4/20/26 Pin: 105407).

The facility is a single-story structure located in a residential neighborhood and consists of the following: (6) bedroom of which (4) are resident bedrooms, and (2) are staff bedrooms, (1) resident bathroom, (1) staff bathroom, a living room, dining room, kitchen, an attached garage with washer and dryer/ storage area, and a backyard with table and chairs. Please note that the staff have there own separate kitchen and living room. All resident bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to residents. The water temperature properly measured between 105-120 F.. A supply of perishable and non-perishable food was observed, toxins and knifes were stored and inaccessible to residents, no weapons nor bodies of water on the premises, exits and walkways are free of debris/hazards.

LPA conducted a records review of 3 staff records, 3 client records, and 3 medication administration records, Medications were centrally stored and properly locked. A first aid kit was checked and fully stocked, 2 fire extinguishers fully charged, carbon monoxide and smoke detectors are interconnected and operational.

Deficiencies cited on 809 D. Exit interview conducted, appeal rights explained, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Lizeth Villegas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2026
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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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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Document Has Been Signed on 04/20/2026 08:51 AM - It Cannot Be Edited


Created By: Lizeth Villegas On 04/17/2026 at 02:21 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: FLORESMA GUEST HOME

FACILITY NUMBER: 198320262

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 04/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
87411 Personnel Requirements - General
All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

Deficient Practice Statement
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Based on [(observation) (record review)], the licensee did not comply with the section cited above as LPA did not observe a current/active CPR/First aid certificate for staff 1-3 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2026
Plan of Correction
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Licensee/Administrator to ensure all staff who provide assistance to residents in care obtain a CPR/First aid certificate. Copies of certificates to be sent to LPA by POC due date. Lizeth.villegas@dss.ca.gov
Type B
Section Cited
CCR
87411(f)
87411 Personnel Requirements - General
All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
Deficient Practice Statement
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Based on [(observation) and (record review)], the licensee did not comply with the section cited above as LPA did not observe a health screening on file for staff #1-2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2026
Plan of Correction
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Licensee/Administrator to obtain a health screening signed by a licensed physician and submit a copy to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Lizeth Villegas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/20/2026 08:51 AM - It Cannot Be Edited


Created By: Lizeth Villegas On 04/17/2026 at 02:26 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: FLORESMA GUEST HOME

FACILITY NUMBER: 198320262

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 04/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)
87458 Medical Assessment
The licensee shall obtain an updated medical assessment when required by the Department.


Deficient Practice Statement
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Based on [(observation) and (record review)], the licensee did not comply with the section cited above as LPA did not observe a current physicians report for Resident #1 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2026
Plan of Correction
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Licensee/Administrator to obtain a current medical assessment/physicians report and submit a copy to LPA by POC due date.
Type B
Section Cited
CCR
87458(c)(1)(A)
87458 Medical Assessment

The medical assessment shall include, but not be limited to: A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: Communicable tuberculosis.

Deficient Practice Statement
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Based on [(observation) and (record review)], the licensee did not comply with the section cited above as LPA did not observe documentation that TB test was conducted for resident #2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2026
Plan of Correction
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Licensee/Administrator to obtain a tb test for resident #2 and sent LPA a copy of test conducted with results by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Lizeth Villegas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 04/20/2026 08:51 AM - It Cannot Be Edited


Created By: Lizeth Villegas On 04/17/2026 at 03:02 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: FLORESMA GUEST HOME

FACILITY NUMBER: 198320262

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 04/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
HSC 1 569.625 Staff training; legislative findings; contents
In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.
Deficient Practice Statement
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Based on [(observation) and (record review)], the licensee did not comply with the section cited above as LPA did not observe training logs or certificates for staff #1-3 on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2026
Plan of Correction
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Licensee to ensure all staff are trained yearly as per regulation cited above. LPA to receive by POC due date copies of any insrevices and/or online traingings conducted. Name of staff in attendance, Time, date, length, and training topics to be included .
Type B
Section Cited
HSC
1569.695(c)
1569.695 Emergency Plans
A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as there was no emergency drill log/documentation for LPA to review nor was staff aware of the last drill conducted which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2026
Plan of Correction
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Licensee/Administrator to conduct emergency drills each quater and document tthe drill date, time, and participants. Facility to conduct a drill and send copy of documentation to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Lizeth Villegas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2026


LIC809 (FAS) - (06/04)
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