306005618-8-7-2026-22-AS-RMRT-DWQV4W-20260807160700

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005618
Report Date: 08/07/2026
Date Signed: 08/07/2026 04:07:07 PM

Document Has Been Signed on 08/07/2026 04:07 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 II		FACILITY NUMBER:	306005618
ADMINISTRATOR/ DIRECTOR:	MOLDOVAN, ANDREEA		FACILITY TYPE:	740
ADDRESS:	502 E MEADOWBROOK AVE		TELEPHONE:	(714) 363-3880
CITY:	ORANGE	STATE: CA	ZIP CODE:	92865
CAPACITY: 6		CENSUS: 6	DATE:	08/07/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Daniela Usurelu, Administrator (AD)		TIME VISIT/ INSPECTION COMPLETED:	04:20 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) Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation. LPA was greeted and granted entry by staff at 1pm. LPA spoke with Administrator (AD) Natalia Surgent, who was out-of-town, and explained the purpose of the visit. AD stated AD Daniela Usurelu was on her way to assist LPA with the visit. The facility is a two-story residential home with a capacity of six non-ambulatory residents of which one may be bedridden and has a hospice waiver for three residents. Currently there are six residents in care, none of which are bedridden. Three residents receive hospice services. During the visit LPA toured the property and observed that sharps and knives were secured in a locked drawer. Chemicals and hazardous materials were stored and secured underneath the sink. Kitchen appliances such as the stove, dishwasher and microwave were in working order. LPA observed there were two days of perishable supplies in the refrigerator and seven days of non-perishable food items on hand. The facility was 77 degrees Fahrenheit and was clean with no odors detected. LPA inspected the smoke and carbon monoxide detectors and they are connected and operational. LPA observed three fire extinguishers that were charged and inspected on August 11, 2025. The facility's last fire drill was on June 26, 2026. LPA observed hallway night lights and there are cameras in common areas with no audio. All exit doors had auditory devices. LPA tested the hot water temperature in three of three bathrooms and the temperatures ranged between 105.2 to 111.0 degrees Fahrenheit. All bathrooms had grab bars and non skid flooring. Resident bedrooms were clean and had all of the required furnishings and (Continued on LIC 809-C)

Alisa Ortiz
RoseMarie Ruppert
	DATE: 08/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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 II	FACILITY NUMBER: 306005618
	VISIT DATE: 08/07/2026

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(Continued from LIC 809)

linens. The licensee lives on the second floor and was out-of-town. All entrances to the second level were locked so there is no access for residents or staff.

LPA observed the See Something, Say Something (PUB 475) and Long Term Care Ombudsman posters posted with the Emergency Disaster Plan, Personal Rights, Resident Council meetings, activities and the weekly menu. Facility liability insurance is current. LPA toured the exterior of the property and there were no hazards or obstruction in pathways. LPA observed shaded seating areas and there was ample space for outdoor activities. The exterior gate was in working order.

LPA audited the centrally stored medications for six of six residents. Per review, medications are being given as prescribed. The facility had all the required elements in the First Aid Kit and had a First Aid book on-site.

LPA reviewed three of three staff training and fingerprint records and conducted a complete review of resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on March 30, 2028. LPA reminded AD regarding licensing fees due to avoid late fees and provided payment information.

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Daniela Usurelu, Administrator (AD) and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: RoseMarie Ruppert
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026

LIC809 (FAS) - (06/04)

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