306005218-8-15-2024-22-AS-AROS-D86QXB-20240815123316

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005218
Report Date: 08/15/2024
Date Signed: 08/15/2024 12:33:40 PM

Document Has Been Signed on 08/15/2024 12:33 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 ORANGE HOME		FACILITY NUMBER:	306005218
ADMINISTRATOR:	SURGENT, NATALIA		FACILITY TYPE:	740
ADDRESS:	816 E MEATS AVE		TELEPHONE:	(714) 366-1858
CITY:	ORANGE	STATE: CA	ZIP CODE:	92865
CAPACITY:	6	CENSUS:	DATE:	08/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:			TIME COMPLETED:	12:45 PM

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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility by care giver David Pakpahan to whom LPA discussed the purpose of the visit.. LPA also discussed the purpose of the visit with Licensee/Administrator Natalia Surgent who accompanied LPA on tour.

According to the facility’s license, the facility has a maximum capacity of six (6) non-ambulatory clients. Facility also has a hospice waiver for 3.

LPA, accompanied Licensee/Administrator Natalia Surgent, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was compliant. Hot water temperature at taps accessible to clients were all compliant.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Centrally stored medications were properly stored and locked in medication cabinet.. Medication logs and medications reviewed were current and medications appear to be administered according to the label instructions.

[Continued on 809-C]

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

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 ORANGE HOME	FACILITY NUMBER: 306005218
	VISIT DATE: 08/15/2024

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No pools or bodies of water on the premises. Per Licensee/Administrator Natalia Surgent , no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA reviewed the theft and loss policy and procedures. Transportation procedures are compliant. Administrator’s certification is current. LPA interviewed staff members and Residents. LPA interviews did not raise any licensing concerns. Staff and resident records review verified that all staff records and residents are complete and compliant. Licensee presented proof of current liability insurance. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs.

An exit interview was conducted with Licensee/Administrator Natalia Surgent, to whom copies of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

LIC809 (FAS) - (06/04)

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