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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320508
Report Date: 10/18/2024
Date Signed: 10/18/2024 11:52:35 AM

Document Has Been Signed on 10/18/2024 11:52 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:ACE ELDERLY HOMEFACILITY NUMBER:
198320508
ADMINISTRATOR/
DIRECTOR:		AGATEP,EVANGELINEFACILITY TYPE:
740
ADDRESS:23223 PRYOR PLACETELEPHONE:
(310) 985-1059
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY: 6CENSUS: 0DATE:
10/18/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Evangeline AgatepTIME VISIT/
INSPECTION COMPLETED:
10:47 AM
NARRATIVE
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On 1018/24, a virtual meeting was held via Microsoft Team by the El Segundo Adult and Senior Regional Office. Present during the meeting were Licensing Program Manager (LPM) Janae Hammond, Licensing Program Analyst (LPA) Ernand Dabuet, and applicant Evangeline Agatep.

The purpose of today's meeting was to obtain clarifications for the facility change of ownership and operations.

The meeting discussed the following:
  • Clarification on change of ownership for Santa Fe Home III (applicant can not hold lease until applicant obtained license).
  • The license is not transferable for Santa Fe Home III.
  • Pre-License Visit conducted 10/17/24 by LPM Jose Calderon.
  • LPM to follow up with CAB for Ace Elderly Home License.
  • Applicant completed Comp III.
  • New Admissions Agreement for Resident (change to Ace Elderly Home).
  • Change of all Licensing Documents from Santa Fe to Ace Elderly Home.
  • Staff Fingerprints (association) only associated with Santa Fe Home III will automatically transfer.
  • Staff Health Screening (make note of the change of ownership)
  • Several facilities will be held by administrator - Casa Del Sur & Ace Elderly Home

The meeting concluded at 10:47 am. An exit interview was conducted with Evangeline Agatep, and a copy of the report was emailed for signature.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2024
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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