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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005232
Report Date: 09/30/2021
Date Signed: 09/30/2021 12:12:33 PM

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 COTTAGE IXFACILITY NUMBER:
306005232
ADMINISTRATOR:NICOLAS OUDINOTFACILITY TYPE:
740
ADDRESS:17332 MELBOURNE LNTELEPHONE:
(909) 534-0132
CITY:YORBA LINDASTATE: CAZIP CODE:
92887
CAPACITY:6CENSUS: 4DATE:
09/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Francis MejiaTIME COMPLETED:
12:15 PM
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Norman Woodridge for the purpose of conducting a Covid-19 Annual Inspection. LPA completed temperature screening upon entry into the facility. LPA met with Administrator (AD) Francis Mejia and discussed the purpose of the inspection. During the inspection, LPA and Staff 1 (S1) conducted a tour of the inside and outside of the facility, common areas, resident rooms, garage, and kitchen.

LPA observed the following:

There were 2 staff and 4 residents present at the facility. Resident rooms were clean and organized. LPA observed a 2-day supply of perishables and a 7-day supply of non-perishables. LPA observed hallways and walkways that were free of obstruction. LPA observed Covid-19 related posters in rest rooms, common areas, and on the outside of the facility. LPA reviewed Covid-19 related training signature sheet, mitigation plan, staff roster, and resident roster. LPA and AD discussed Provider Information Notice 21-38-ASC: Update Guidance for the Use of Masks, Surgical Masks, Respirators Related to Coronavirus Disease 2019 (COVID-19).


No deficiencies were noted during the inspection.

An exit interview was conducted with AD and a copy of this report was provided.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Norman WoodridgeTELEPHONE: (714) 703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
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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