<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320516
Report Date: 10/27/2025
Date Signed: 10/27/2025 02:39:14 PM

Document Has Been Signed on 10/27/2025 02:39 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:HALLDALE GUESTHOMEFACILITY NUMBER:
198320516
ADMINISTRATOR/
DIRECTOR:		AGATEP, EVANGELINEFACILITY TYPE:
740
ADDRESS:23438 HALLDALE AVENUETELEPHONE:
(424) 263-5370
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY: 6CENSUS: 6DATE:
10/27/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:07 PM
MET WITH:ADMINISTRATOR EVANGELINE AGATEPTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/27/2025 around 1pm Licensing Program Analysts (LPA) Jose Calderon conducted an announced visit to Halldale Guest Home Facility located at 23438 Halldale Ave Harbor City CA 90710 and met with Licensee/Administrator Evangeline Agatep for purpose of a pre-licensing evaluation. The facility is licensed to operate six (6) non-ambulatory elderly adults of which two (2) may be bedridden ages 60 and above. Currently, the facility has six (6) residents and one (1) in hospice care. The facility is approved for (2) hospice residents.

Facility is a 4 bedroom, 3 bathrooms, and a one-story house. The client bedrooms are spacious and will easily accommodate the client's furnishings. There is a backyard with a small table and 3 chairs. Outdoor passageways, walkways, driveways, steps, and patios are free from obstructions. LPA Calderon did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Residents Bedrooms: Bedrooms 1,3 have 2 beds and 2, and 4 will have one bed each, one chair, one-night stand, one lamp. Bedrooms 1,2,3 and 4 all comply with the requirement of 8 cubic feet of space. Bathroom1,2: Have a working toilet, wash basins, and walk-in shower. Bathroom #1, #2 shower have grab bars. LPA Calderon observed adequate lighting in hallway leading to bathrooms. Linens & Hygiene Supplies: Beds have the required linen/supplies which include pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in hall closet was noted.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Jose Calderon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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)
Page: 2 of 3
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: HALLDALE GUESTHOME
FACILITY NUMBER: 198320516
VISIT DATE: 10/27/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Emergency Phone Numbers, Exit Plan & Menu: The telephone system is landline and operable. Emergency Disaster Plan and "See something, say something Let Us Know". Fire Extinguisher 1 mounted on the wall next to the kitchen.
Food Service: Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in a lock box located in the kitchen area. Food supply is adequate; stored in kitchen refrigerator and cabinets and consists of the following: A variety of Fresh and Canned fruit, vegetable, and meat food items. Smoke Detectors/carbon monoxide: 7 hard wired smoke detectors are operating & working. Appliances: Gas Stove, oven, microwave, washer, and dryer working. Refrigerator in the kitchen has a measured temperature of at least 37 degrees Fahrenheit for appropriate food storage. Freezer is at zero degrees Fahrenheit. The residence is equipped with central air and heat, and each client bedroom is individually climate controlled. Toxins: Locked/stored in a cabinet located in the kitchen. Water Temperature: Bathrooms’ water temperature tested at 110 F. and #2 at 110 F. degrees. Kitchen water temperature tested at 112 degrees. Medications, First-Aid Kit & Book: Medication administration records storage area, and first aid kit has been inspected, which are stored in lock box located in a cabinet adjacent the refrigerator, available for staff use but inaccessible to clients.

Clients & Staff Files: Records of staff and clients shall be stored in a locked-in staff office, and the section has been inspected.

Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the client's use. LPA Calderon did not observe any pet or bodies of water at the facility. LPA Calderon did not observe delayed egress, chain locks or dead bolts on exits. LPA Calderon did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on side gates and front exits. Pool/Jacuzzi & Pets: LPA Calderon did not observe any pet or bodies of water at the facility. Fire clearance: Fire Clearance was approved on 08/19/2024 for six (6) non-ambulatory elderly adults of which two (2) may be bedridden ages 60 and above.



An exit interview was conducted, and a copy of this report has been furnished by the applicant Evangeline Agatep by hand. Accordingly, LPA Jose Calderon will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Jose Calderon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3