306005232-9-17-2024-22-AS-MTEA-D97PZK-20240917114540

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005232
Report Date: 09/17/2024
Date Signed: 09/17/2024 11:46:00 AM

Document Has Been Signed on 09/17/2024 11:46 AM - 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 COTTAGE IX		FACILITY NUMBER:	306005232
ADMINISTRATOR:	NICOLAS OUDINOT		FACILITY TYPE:	740
ADDRESS:	17332 MELBOURNE LN		TELEPHONE:	(909) 534-0132
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92887
CAPACITY:	6	CENSUS: 6	DATE:	09/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:18 AM
MET WITH:	Francis Mejia		TIME COMPLETED:	12:00 PM

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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. At around 8:18 AM, LPA Tea was greeted and granted entry into the facility by caregiver Maycelina Dagdag and explained the reason for the visit. The Licensee (LE) Francis Mejia arrived shortly to assist with the visit. The facility is licensed for 6 non-ambulatory residents with a hospice waiver for six, in which one may be bedridden. Currently there are six residents, of which four residents are on hospice during today's visit.

Around 8:37 AM, LPA Tea reviewed six resident files and two staff files. Resident files and staff files contained all required documentation. Upon review of records, the facility is out of date with quarterly disaster drills, which was last conducted on April 11, 2024. LPA advise to conduct a disaster drill soon. Administrator (AD) Shelly Yamashiro’s certificate expires on October 06, 2025.

LPA Tea along with LE Mejia toured the facility at 9:50 AM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a single-story home that consists of 4 resident bedrooms, 1 staff room, 2 bathrooms, living room, family room, dining room, kitchen, and a garage. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Water temperature measured between 115.8 F degrees and 120 F degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit.

Annual continuation on LIC809-C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

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 COTTAGE IX	FACILITY NUMBER: 306005232
	VISIT DATE: 09/17/2024

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LPA observed sharps locked in the drawer but the lock for the drawer is broken and sharps are currently stored in a locked closet by the dining room where the medication is securely stored. LPA also observed toxin substances to be locked and inaccessible to clients in care underneath the kitchen sink. The fire extinguishers throughout the facility hallways were fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating underneath a shaded patio area in the backyard. There are two exit gates that are self-latching and operational on both sides of the house. LPA observed emergency food and water stored in cabinets in the family room. Facility provides activities based on their personal choice. Residents walk around facility grounds. There was a fitness instructor that comes to do exercises and physical therapy with residents. At the time of the visit, LPA observed residents watching television and playing with the computer.

LPA reviewed medication storage and administration. Medications are stored in a locked storage closet by the dining room. Medications are being administered per physician order. LPA interviewed residents regarding their quality of care and spoke to staff present regarding care provided.

Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with Licensee Francis Mejia and a copy of this report LIC809, along with the 809-C, LIC858, LIC858-C, LIC859, LIC9102TA and LIC9102TV were read and provided to the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC809 (FAS) - (06/04)

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