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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006525
Report Date: 07/08/2025
Date Signed: 07/08/2025 12:33:35 PM

Document Has Been Signed on 07/08/2025 12:33 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ABK ANGELS HOMECARE, INC.FACILITY NUMBER:
306006525
ADMINISTRATOR/
DIRECTOR:		TRUONG, BRENDA K.AFACILITY TYPE:
740
ADDRESS:10122 NORTHAMPTON AVETELEPHONE:
(714) 837-1823
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY: 6CENSUS: 6DATE:
07/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Brenda Truong, Kristine TruongTIME VISIT/
INSPECTION COMPLETED:
12:47 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by a caregiver staff and explained the reason for the visit. Administrators (AD) Kristine Truong and Brenda Truong arrived shortly to assist with the visit. The facility is licensed for a capacity of six, approved for six non-ambulatory, with a hospice waiver of four. Currently there are six residents, and there are two on hospice during today's visit.

LPA Tea reviewed six resident files and four staff files. Resident files contained most of the required documents, except four of the residents does not have updated physician’s report. Staff records met all requirements. The administrator certificate expires on January 17, 2026.

LPA Tea along with staff toured the facility. LPA toured the physical plant, checked food service, and the first aid kit. The home is a one-story facility that consists of 5 resident bedrooms, 2 full bathrooms, living room, kitchen, dining area, and attached garage. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Water temperature measured between 108.1 Fahrenheit degrees and 115.5 Fahrenheit degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements

Annual Inspection continued LIC809C

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Michael Tea
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2025
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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Document Has Been Signed on 07/08/2025 12:54 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/08/2025 12:40 PM


Created By: Michael Tea On 07/08/2025 at 11:30 AM
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ABK ANGELS HOMECARE, INC.
FACILITY NUMBER: 306006525

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 LPA's review of resident records, 4 out of 6 residents do not have updated physician's report. This poses as a potential health and safety risk to residents in care.

**This is an amended report**
POC Due Date: 07/29/2025
Plan of Correction
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Licensee will obtain the physician's report for residents that do not have current updated ones and send copies by POC due date to LPA
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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Michael Tea
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/08/2025 12:55 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/08/2025 12:44 PM


Created By: Michael Tea On 07/08/2025 at 11:38 AM
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ABK ANGELS HOMECARE, INC.
FACILITY NUMBER: 306006525

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation ... (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation during the physical plant tour, LPA discovered a broken dresser missing a drawer in Room #5. Also LPA discovered broken toilet paper holder in the bathroom. This poses as a potential health and safety risk to residents in care.
** This is an amended report **
POC Due Date: 07/29/2025
Plan of Correction
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Administrators will replace and fix items noted from LPA's obersvation and provide proof to LPA by POC due date.
Type B
Section Cited
HSC
1569.695
Emergency Plans(a)(2) ... Facility must plan to be self-reliant for a period of at least 72 hours immediately following any emergency or disaster (including a long-term power failure).


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, there is insufficient drinking water to support residents in care for 72 hours. Additional water bottles or jugs should be available to support the residents.
POC Due Date: 07/29/2025
Plan of Correction
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Administrators will provide proof of sufficient emergency supplies 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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Michael Tea
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2025


LIC809 (FAS) - (06/04)
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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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ABK ANGELS HOMECARE, INC.
FACILITY NUMBER: 306006525
VISIT DATE: 07/08/2025
NARRATIVE
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including dressing, bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps secured in a kitchen drawer. LPA also observed toxin substances to be secured and locked and inaccessible to clients underneath the kitchen sink and garage. The fire extinguishers throughout the facility are fully charged. The facility’s last fire drill was conducted on January 27, 2025. Kitchen appliances are operational during today's visit. LPA observed emergency food and water supply in the kitchen and garage. There was not enough water for residents in case of emergency. LPA toured the outside grounds. There is a shaded patio area for residents to sit outside. The gates on both sides of the house are self-latching and operational. Facility provides activities based on resident’s personal preference and health condition and limitations. There are activities like coloring and reading provided for residents. There are group discussions, and an activities person comes to the facility from time to time. At the time of the visit, LPA observed residents watching TV and enjoying lunch.

LPA reviewed medication storage and administration. Medications are stored in a locked cabinet in the kitchen. Medications are being administered per physician orders. LPA advises facility needs to list PRNs on their centrally stored medications list. LPA interviewed clients regarding their quality of care and spoke to the staff present regarding care provided.

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with Administrators Brenda Truong and Kristine Truong and a copy of this report LIC809, 809-C, LIC809-D, LIC858, LIC859 were read and provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Michael Tea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC809 (FAS) - (06/04)
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