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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270708695
Report Date: 03/21/2022
Date Signed: 03/21/2022 03:56:36 PM


Document Has Been Signed on 03/21/2022 03:56 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
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: 5DATE:
03/21/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Administrator Miriam FickewirthTIME COMPLETED:
04:15 PM
NARRATIVE
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On 3/21/2022, Licensing Program Analyst (LPA) Jaclyn Avila conducted an unannounced complaint investigation visit, and met with Miriam Fickewirth Administrator/Licensee and Herman Fickewirth. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95.

During the course of the complaint visit, LPA conducted an inspection with Herman Fickewirth at Marie's direction, to ensure the health and safety of residents in care. LPA observed the following deficiencies:

At 8:47 AM, LPA inspected outside storage containers that were locked behind a gate on the patio behind the facility. LPA observed a sample of the stored food and found expired Tomato sauce as of April 17, 2020, Expired Miso Broth as of March 22 2021, expired dill pickles as of July 2017, expired broccoli cream soup as of October 31, 2021.
At 9:42 AM, LPA inspected the inside kitchen fridge with Miriam and found expired juice as of November 20, 2020, expired nutrition shake as of March 2016, expired dressing September 1st, 2021, expired yogurt as of 11/24/2020, expired Gatorade as of December 04, 2021, expired cashews as of April 2014, expired deli meat as of November 9th, 2021.

At 9:39 AM and at 9:53 AM, LPA found 2 of 2 fire extinguisher observed were last serviced Nov 11, 2019. LPA Contacted the Cypress Fire Protection Agency and left a message for Fire Marshall John Reynolds. LPA requested a call back regarding local fire regulations.
The following deficiencies were cited per Title 22 of the California Code of Regulation See 809D. Appeal Rights were explained and provided to the facility representative listed above and an Exit Interview was conducted. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022
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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Document Has Been Signed on 03/21/2022 03:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA


FACILITY NAME: AGAPE OF CARMEL
FACILITY NUMBER: 270708695

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/22/2022
Section Cited

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87555(a) General Food Service Requirements-
The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents ...All food shall be selected, stored, prepared and served in a safe and healthful manner.
This requirement is not met as evidenced by
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Based upon observationthe Licensee failed to ensure the quality of food at the facility. Expired non-perishable food was located ouside in storage and expired perishable food was located in the kitchen fridge accessible to residents in care.
This poses an immediate Health, Safety and/or Personal Rights risk to residents in care.
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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.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022
LIC809 (FAS) - (06/04)
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