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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320394
Report Date: 09/28/2025
Date Signed: 09/28/2025 03:36:34 PM

Document Has Been Signed on 09/28/2025 03:36 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:ANGEL'S ON WING'S LLCFACILITY NUMBER:
198320394
ADMINISTRATOR/
DIRECTOR:		CLANTON, MARILYNFACILITY TYPE:
740
ADDRESS:1440 W 92ND STREETTELEPHONE:
(310) 684-8859
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY: 6CENSUS: 5DATE:
09/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:21 AM
MET WITH:Marilyn Clanton, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On 09/28/25 at 10:21AM, Licensing Program Analyst (LPA) Gina Saucedo, arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA Saucedo met with Caregiver, Phillip Pryce and disclosed the purpose of the visit. The Administrator, Marilyn Clanton, arrived about forty (40) minutes later.

LPA asked for the census, resident, and staff files. A physical tour was conducted at 10:30am and observed the following:

The Kitchen area was toured, and LPA observed there to be sufficient seven (7) day supply of non-perishable foods and perishable food for all residents. The kitchen area was clean at the time of the tour. The fire extinguisher is located against the wall on your right-hand side of the kitchen. It is fully charged dated 09/2025. There is extra, food emergency kits in the kitchen and in the kitchen pantry. The sharps are locked and inaccessible to the residents in one (1) of the right side cabinets and chemicals/toxins are also kept in this area that are locked and inaccessible to the residents.

The medication is also locked and inaccessible to the residents on the left hand side of a cabinet in the hallway.

Outside/Backyard: There is a ramp in the back of the facility. The outside/backyard has furniture for residents with proper seating. The facility has a cameras in common areas. The facility has no pool or bodies of water. There is no garage.

LIC 809C-continued
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Gina Saucedo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2025
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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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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: ANGEL'S ON WING'S LLC
FACILITY NUMBER: 198320394
VISIT DATE: 09/28/2025
NARRATIVE
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Bedrooms and Bathrooms: There are six (6) bedrooms and two (2) bathrooms.. There are six (6) bedrooms that are for resident use with no bathroom. Two (2) bedrooms are currently unoccupied. All bedrooms and bathrooms were toured and were properly furnished and have appropriate bedding, linens, toiletry and lightning. The bathrooms have proper toiletry and grab bars. There are chemicals/toxins that are kept in this area also in a cabinet that are locked and inaccessible to the residents. The bathroom temperatures of the water are within regulations reading at 115 degrees Fahrenheit. There is no staff bedroom. There is also an office that is locked in the hallway.

The dining area/living room area has enough seating for the residents and the staff. There is a large television against the wall and there is also internet access and telephone access. There is another fire extinguisher in this area dated 09/2025.

There is one (1) washer and dryer that is kept in the hallway.

The carbon monoxide and smoke detectors are located throughout the facility and are operable and interconnected. The house temperature is set at 72 degrees. There are two (2) more fire extinguishers down the hallways dated 09/2025.

Administrative: At the entrance of the facility against the wall, there is YES signs, Emergency Disaster Plan, Patient Rights, Personal Rights, Facility Sketch, Ombudsman sign, Oxygen sign, no smoking, the insurance plan is updated and is dated 12/19/2025. The last emergency disaster drill was July of 2025.

Staff and Resident Files were reviewed: Three (3) out of three (3) staff files were reviewed. Six (6) out of six (6) resident files were reviewed. Four resident files were missing physician's report/tuberculosis, Six resident files were missing resident appraisal, pre-appraisal, functional capabilities and appraisal needs and services.

An exit interview was conducted, citation(s) were issued, appeal rights was provided and a copy of this report was given to the administrator.
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Gina Saucedo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 09/28/2025 03:36 PM - It Cannot Be Edited


Created By: Gina Saucedo On 09/28/2025 at 01:25 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: ANGEL'S ON WING'S LLC
FACILITY NUMBER: 198320394

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(i)
Maintenance and Operation
(i) Facilities shall have signal systems which shall meet the following criteria:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the observation the licensee did not comply with the section cited above in two out of two areas-front door and back door need a signal system for two dementia residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2025
Plan of Correction
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Licensee/Administrator failed to have a signal system for dementia residents and will have to install one on the front door and back door and send a picture to the LPA of signal system installation.
Type B
Section Cited
CCR
87506(b)(17)(B)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (B) Section 87459, Functional Capabilities;

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review the licensee did not comply with the section cited above in six (6) out of six (6) residents did not have a functional capability form which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2025
Plan of Correction
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Licensee/Administrator is to document, print and file the functional capability form for six(6) residents.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Eva M Alvarez
NAME OF LICENSING PROGRAM MANAGER:
Gina Saucedo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/28/2025 03:36 PM - It Cannot Be Edited


Created By: Gina Saucedo On 09/28/2025 at 01:25 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: ANGEL'S ON WING'S LLC
FACILITY NUMBER: 198320394

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review the licensee did not comply with the section cited above inin six (6) out of six (6) residents did not have a pre-admission appraisal/pre-placement form which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2025
Plan of Correction
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Licensee/Administrator is to document, print and file the pre-admission appraisal/pre-placement form for six(6) residents.
Type B
Section Cited
CCR
87458(c)(1)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) 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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review the licensee did not comply with the section cited above in four (4) out of four (4) residents did not have their medical diagnosis/physician's form which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2025
Plan of Correction
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Licensee/Administrator is to document, print and file the medical diagnosis/physician's form for four (4) residents.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Eva M Alvarez
NAME OF LICENSING PROGRAM MANAGER:
Gina Saucedo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/28/2025 03:36 PM - It Cannot Be Edited


Created By: Gina Saucedo On 09/28/2025 at 01:25 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: ANGEL'S ON WING'S LLC
FACILITY NUMBER: 198320394

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) 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: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review the licensee did not comply with the section cited above in four (4) out of four (4) residents did not have their tuberculosis form which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2025
Plan of Correction
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Licensee/Administrator is to document, print and file the tuberculosis form for four (4) residents.
Type B
Section Cited
CCR
87463(h)(1)
Reappraisals
(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 the record review the licensee did not comply with the section cited above in six (6) out of six (6) residents did not have a resident reappraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2025
Plan of Correction
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Licensee/Administrator is to document, print and file the reappraisal form for six (6) residents.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Eva M Alvarez
NAME OF LICENSING PROGRAM MANAGER:
Gina Saucedo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 09/28/2025 03:36 PM - It Cannot Be Edited


Created By: Gina Saucedo On 09/28/2025 at 01:25 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: ANGEL'S ON WING'S LLC
FACILITY NUMBER: 198320394

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(e)(2)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on the record review the licensee did not comply with the section cited above in six (6) out of six (6) residents did not have a resident needs and services plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2025
Plan of Correction
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2
3
4
Licensee/Administrator is to document, print and file the resident needs and services plan form for six (6) residents.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Eva M Alvarez
NAME OF LICENSING PROGRAM MANAGER:
Gina Saucedo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2025


LIC809 (FAS) - (06/04)
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