306004665-8-22-2024-22-AS-EKIM-D8DVFW-20240822162437

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004665
Report Date: 08/22/2024
Date Signed: 08/22/2024 04:24:41 PM

Document Has Been Signed on 08/22/2024 04:24 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
ORANGE COUNTY RO, 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: 5	DATE:	08/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Natalia Surgent		TIME COMPLETED:	04:35 PM

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On August 22, 2024, at 2:00pm, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Administrator (AD) Natalia Surgent and explained the purpose of the visit.

The facility is licensed to operate for six (6) non-ambulatory of which one (1) may be bedridden and have a hospice waiver for three (3) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) resident bedrooms, one (1) staff bedroom, two (2) bathrooms, family area, dining room, kitchen, attached 2-car carport, two sheds out in the backyard, and an outside covered patio area.

LPA Kim toured indoor and outdoor of the physical plant with AD Surgent. There are no obstructions or bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. The fireplace is covered with a screen. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All bedrooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, Resident Room 5, Resident Room 6, and Staff Room 1. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 106.8 degrees F and 107.7 degrees F. A comfortable temperature of 78 degrees F was maintained in the facility.

LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food, water, supplies are stored in the pantry and extra emergency water in the dining room. The facility has two (2) fire extinguisher that is charged, mounted in the kitchen and in the residential hallway, and both were serviced in February 23, 2024 and smoke/carbon monoxide detectors were operable.

Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: AGAPE SENIOR LIVING	FACILITY NUMBER: 306004665
	VISIT DATE: 08/22/2024

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During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). The facility conducts Fire/Safety Drill quarterly and was last conducted June 7, 2024. A working telephone (657-258-0007) remains available. First Aid Kit contained all the necessary elements.

LPA conducted an audit of resident files (R1-R5), staff files (S1-S3) and medication and medication administration review that were all in order and complete. LPA Kim conducted 3 resident interviews and 1 staff interviews.

An exit interview was conducted and a copy of this report was provided to Administrator Natalia Surgent.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC809 (FAS) - (06/04)

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