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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004665
Report Date: 08/27/2021
Date Signed: 08/27/2021 12:27:19 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/27/2021 12:27 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:AGAPE SENIOR LIVINGFACILITY NUMBER:
306004665
ADMINISTRATOR:NATALIA SURGENTFACILITY TYPE:
740
ADDRESS:4821 TORIDA WAYTELEPHONE:
(657) 444-9715
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 6CENSUS: 6DATE:
08/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Natalia and Cornel SurgentTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Michelle Reed made an unannounced visit to the facility to conduct an Annual visit. The visit was conducted to assess Infection Control due to the COVID19 pandemic. Upon arrival LPA met with Staff Debbie and Djoni Longkutoy. Administrators Natalia and Cornel Surgent arrived a short time later. During the visit LPA toured the facility with Debbie Longkutoy and the following was observed:

Covid signage was posted at the front entrance of facility with a sanitization station. LPA's temperature was taken upon arrival and a sign in sheet was made available. Facility has required Department postings. Administrator Certificate for Natalia Surgent expires 2/9/22. LPA toured all resident rooms. Rooms were clean and sanitary. All restrooms observed contained soap, paper towels and toilet paper. Hand sanitizer, soap, wipes and gloves were present. The Licensee has at least a 30 day supply of PPE. LPA observed an outside visitation area with ample shading. Residents were having lunch. Licensee has required Mitigation plan and Emergency Disaster Plan. LPA observed emergency food and water supply. Facility has a secured location for resident medication and files.

During the visit, LPA consulted with staff regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA advised the importance of mask wearing and handwashing for staff. Administrator is reminded to review PIN 20-17.2-ASC in regards to Visitation, Dining, Group Activities, Non-essential services, Outings, New Admissions and Entertainment. PIN 21-32-ASC provides Updated Staff Testing and Masking Guidelines. No deficiencies noted during visit. An exit interview was conducted with and a copy of this report was provided to Ms. Surgent.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2021
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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