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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270708695
Report Date: 07/09/2021
Date Signed: 10/05/2021 03:00:49 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:AGAPE OF CARMELFACILITY NUMBER:
270708695
ADMINISTRATOR:FICKEWIRTH, MIRIAMFACILITY TYPE:
740
ADDRESS:25527 FLANDERS DRIVETELEPHONE:
(831) 626-1032
CITY:CARMELSTATE: CAZIP CODE:
93923
CAPACITY:6CENSUS: 4DATE:
07/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Miriam Fickewirth and Michael HagertyTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection Infection Control site visit and met with Miriam Fickewirth Administrator and Michael Hagerty Co-Administrator.

LPA toured the facility inside and out to include the entry, bedrooms and bathrooms, kitchen, dining room, living room, laundry room, storage and exterior. All fire exit routes were free and clear of obstructions. Medications are stored in a locked medication cabinet in the kitchen. Toxins, cleaning supplies, knives and sharp objects are secured.

Facility observed to have designated entry point for universal symptom screening with questionnaire. Bathrooms observed to be supplied with hygiene products. Hand washing signs were posted in bathrooms. Hand sanitizer available to residents and visitors. LPA observed to have adequate supply of Personal Protective Equipment (PPE).

LPA reviewed the facility policies and procedures to include screening, isolation, disinfecting, staffing, training, supplies, PPE usage and social distancing.

No citations were issued per the California Code of Regulations, Title 22.

LPA reviewed report with Miram Fickewirth Administrator and Michael Hagerty Co-Administrator and a copy provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021
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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