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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320394
Report Date: 09/17/2026
Date Signed: 09/18/2026 04:58:48 PM

Document Has Been Signed on 09/18/2026 04:58 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
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:
09/17/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Phillip PyrceTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Annual Required 1 Year Visit with a primary focus on infection control measures and the use of the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the evaluation, the facility is clear of COVID-19 infection.

LPA Bunker met with Phillip Pyrce, Care Provider, and explained the purpose of today's annual inspection. LPA verified that the facility has an approved Mitigation Plan Report and Infection Control Report. There are currently five (5) residents in placement. The facility's annual fees are up to date.

There are 12 Domains in the Infection Control Practices will be observed and reviewed. "I will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections."

LPA Bunker and Care Provider Phillips conducted a tour of the facility, a single-story family home located in a residential neighborhood. The home includes a living room, dining area, kitchen, six bedrooms, two bathrooms, an office, a laundry area, and an indoor/outdoor activity space. The outdoor area is shaded and furnished with patio tables and chairs. Bedrooms #1–#6 are designated for resident use.

See continued LIC809-C page 2

Stephanie Cifuentes
Pamela Bunker
DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2026
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ANGEL'S ON WING'S LLC
FACILITY NUMBER: 198320394
VISIT DATE: 09/17/2026
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Continued LIC 809-C, Page 2

LPA Bunker observed the facility’s infection control practices, which included screening protocols for residents and visitors, readily available hand sanitizer, a visitor log, and the use of thermometers. Logs documenting daily COVID-19 screenings and temperature checks for both residents and staff were present. Personal Protective Equipment (PPE) was easily accessible to staff, with additional supplies on hand. The facility also maintained adequate liquid soap, paper products, cleaning materials, and disinfectants.

Required documents were properly posted in the dining and living room areas. The following Title 22-regulated areas were audited and found to be in compliance: Bedrooms contained the required furniture, and bathrooms were clean and operational. Personal accommodations supported resident safety, privacy, and comfort, including the use of non-skid mats. The kitchen was evaluated for its ability to safely prepare and serve food. Food service and storage were reviewed, and the facility maintained an ample supply of perishable and nonperishable items.

Resident medications were reviewed for proper storage, documentation, and system implementation. Medications were secured in the hallway, and all records were current. Common areas were observed to be clean, free of hazards, and suitable for meeting residents’ needs. The first aid kit was fully stocked. Smoke detectors and carbon monoxide detectors were in compliance. Hot water temperature measured 120 degrees Fahrenheit, within the allowable range of 105 to 120 degrees Fahrenheit. Fire extinguishers were fully charged, linens were adequately supplied, and the facility’s telephones were tested and found operational.

Resident bedroom windows did not have sliding window locks with thumbscrews. All exit doors were in compliance. The yard was free of debris and hazards, and trash cans were properly covered. Staff have completed training on reporting dependent adult and elder abuse. The most recent fire clearance was dated July 27, 2026.

Due to time constraints and technical difficulties, LPA Bunker will return at a later date to conclude the visit.

No deficiencies were cited. An exit interview was conducted.

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Pamela Bunker
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC809 (FAS) - (06/04)
Page: 3 of 3