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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270708695
Report Date: 07/06/2023
Date Signed: 07/10/2023 04:06:45 PM


Document Has Been Signed on 07/10/2023 04:06 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710



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:
07/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Miriam Fickewirth - LicenseeTIME COMPLETED:
03:45 PM
NARRATIVE
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On 7/6/2023, Licensing Program Analyst(LPA) D. Ayers arrived unannounced at the facility to conduct a Required Annual Inspection. LPA met with Licensee Miriam Fickerwirth and Co-Administrator Michael Hagerty.

LPA toured the facility inside and outside. Pathways and doors were clear and free from obstruction. Smoke-detectors and carbon-monoxide detectors were present and operational. Facility was clean and odor free. LPA observed sufficient amount of perishable and non-perishable foodstuffs. Common areas were clean, adequately furnished, and adequately lit. Resident bedrooms were clean and had required minimum furnishings. Resident bathrooms were clean, odor free, and water temperature was within required temperature range. Sharp items were secured in a locked drawer. A locked cabinet was observed to store resident medications, and medications appeared to be administered properly. LPA reviewed facility plan of operations and emergency disaster plan. LPA reviewed a sample of resident files. During Records Review, LPA observed that Resident 1, who was diagnosed with dementia, had a most recent physician's report LIC 602A which was dated 5/25/2021. See attached 809D for deficiency cited in accordance with California Code of Regulations Title 22, Division 6, chapter 8, Article 12, Section 87705(c)(5).

LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan, and a copy of current Administrator’s Certificate to update the facility file.
Exit interview conducted with Licensee and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023
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 07/10/2023 04:06 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: AGAPE OF CARMEL
FACILITY NUMBER: 270708695

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
87705 Care of Persons with Dementia(c)Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
This requirement is not met as evidenced by: Based on records review, Resident 1 physician's report is dated 5/25/2021.
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above for one out of five residents, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2023
Plan of Correction
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Licensee agreed to have Resident 1 reassessed and provide CCLD with a new physician's report (LIC 602A) by POC due date. Licensee will establish a system to track residents' physicians reports and assessments if they are diagnosed with dementia or mild cognitive impairment.
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.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023
LIC809 (FAS) - (06/04)
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