306004665-8-23-2022-22-AS-ETAA-CHKU4A-20220823151450

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004665
Report Date: 08/23/2022
Date Signed: 08/23/2022 03:15:00 PM

Document Has Been Signed on 08/23/2022 03:15 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 LIVING		FACILITY NUMBER:	306004665
ADMINISTRATOR:	NATALIA SURGENT		FACILITY TYPE:	740
ADDRESS:	4821 TORIDA WAY		TELEPHONE:	(657) 444-9715
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	6	CENSUS: 6	DATE:	08/23/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:36 PM
MET WITH:	Agus Sinoman, Tio Loan Gek, Kevin Surgent, Andrea Moldovan		TIME COMPLETED:	03:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with staff Agus Sinoman and Tio Loan Gek and stated the purpose of this visit. Administrators Kevin Surgent and Andrea Moldovan arrived later during the inspection to provide assistance The facility is a single level structure and licensed for six non-ambulatory of which three can be on hospice and one may be bedridden. This facility is a Residential Care Facility for the Elderly. At about 1:36 PM, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed 6 residents in care and 2 staff members on duty. LPA toured the interior and exterior portions of the facility. There were 6 resident rooms all were private rooms. The facility also had a staff room which is inaccessible to residents. Resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide and auditory exit alarms were tested to be operational. Bathrooms were observed to be in good repair and provided with grab bars and hot water was measured from 109.0 – 109.4 degrees Fahrenheit. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements, cleaning supplies and sharp items were inaccessible to residents in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguishers were observed. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. Backyard had 2 storage units and a shaded area for residents. Facility did not have a garage. Laundry room was equipped with an operational washer and dryer. Kitchen was kept clean with medications kept locked. Administrator was made aware of annual fee due on 08/25/2022. Administrator paid annual fee and was provided with a confirmation number.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 LIVING	FACILITY NUMBER: 306004665
	VISIT DATE: 08/23/2022

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LPA Tapia viewed the COVID 19 mitigation plan and the Emergency disaster plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed. No citation was issued. No advisory was issued today.

LPA Tapia conducted an exit interview with Administrator Kevin Surgent and copy of this report was explained and left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022

LIC809 (FAS) - (06/04)

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