270708695-3-21-2022-26-AS-KHOS-CDEPWZ-20220412114135

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 270708695
Report Date: 03/21/2022
Date Signed: 03/21/2022 03:20:36 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/13/2020 and conducted by Evaluator Jaclyn Avila

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20201013130409

FACILITY NAME:	AGAPE OF CARMEL		FACILITY NUMBER:	270708695
ADMINISTRATOR:	FICKEWIRTH, MIRIAM		FACILITY TYPE:	740
ADDRESS:	25527 FLANDERS DRIVE		TELEPHONE:	(831) 626-1032
CITY:	CARMEL	STATE: CA	ZIP CODE:	93923
CAPACITY:	6	CENSUS: 5	DATE:	03/21/2022
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Administrator Miriam Fickewirth		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility not walker/wheelchair accessible

INVESTIGATION FINDINGS:

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On 3/21/2022, Licensing Program Analyst (LPA) Jaclyn Avila conduc
On 3/21/22, this department conducted an inspection and found that not all outed an unannounced complaint investigation visit regarding the above allegations, and met with Miriam Fickewirth Administrator/Licensee. 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.

California Department of Social Services (CDSS) Community Care Licensing (CCL) has investigated this complaint and following are the findings:
tdoor and indoor passageways are being kept free of obstruction. The obstructions observed do not allow for someone who depends on assistive devices such as a walker or wheelchair to utilize these passageways.
Cont'd on LIC 9099-C

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20201013130409

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: AGAPE OF CARMEL	FACILITY NUMBER: 270708695
	VISIT DATE: 03/21/2022

NARRATIVE

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At 8:30 AM, this department observed the passage way to the patio from the dining room to be obstructed by two bird cages. Administrator moved the birds outside however they were still obstructing ones ability to exit if dependant on a wheelchair.

At 9:22 AM, this department observed room #5. This department observed the passage way to the outside was obstructed by an upholstered wooden chair and an ottoman. The resident in this room utilizes both a walker and a cane. Resident stated its difficult to move the furniture due to physical limitations but does like to open the exit door in order to get fresh air. The exterior exit leads to a sun room that has an exit to the outside.

Substantiated: Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. 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 Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/13/2020 and conducted by Evaluator Jaclyn Avila

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20201013130409

FACILITY NAME:	AGAPE OF CARMEL		FACILITY NUMBER:	270708695
ADMINISTRATOR:	FICKEWIRTH, MIRIAM		FACILITY TYPE:	740
ADDRESS:	25527 FLANDERS DRIVE		TELEPHONE:	(831) 626-1032
CITY:	CARMEL	STATE: CA	ZIP CODE:	93923
CAPACITY:	6	CENSUS: 5	DATE:	03/21/2022
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Administrator Miriam Fickewirth		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Food left uncovered on the counter and exposed to bacteria

INVESTIGATION FINDINGS:

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On 3/21/2022, Licensing Program Analyst (LPA) Jaclyn Avila conducted an unannounced complaint investigation visit regarding the above allegations, and met with Miriam Fickewirth Administrator/Licensee. 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.

This department has investigated the above allegation which was made in October 2020 and found the allegation to be unsubstantiated. Witness interviews and departments observations did not support the allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted and report provided to Administrator.

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20201013130409

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 CCR 87307(d)(6)	1 2 3 4 5 6 7	87307(d)(6)-Personal Accommodations and Services-All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Based upon observation and interview the Licensee failed to	1 2 3 4 5 6 7	Licensee agrees to keep passageways free of obstructions. Licensee will review regulation 87307, 87303 and 87705 and familiarize staff. Licensee will submit a letter of understanding to LPA via e-mail on 3/22/22
	8 9 10 11 12 13 14	ensure all outdoor and indoor passageways are free from obstruction This poses an immediate Health, Safety and/or Personal Rights risk to clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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