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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005993
Report Date: 06/09/2021
Date Signed: 06/10/2021 11:44:10 AM

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 SENIOR IIFACILITY NUMBER:
306005993
ADMINISTRATOR:SURGENT, COSMINFACILITY TYPE:
740
ADDRESS:4730 EAST MAYCHELLE DRIVETELEPHONE:
(714) 366-5468
CITY:ANAHEIMSTATE: CAZIP CODE:
92807
CAPACITY:6CENSUS: 0DATE:
06/09/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Cosmin SurgentTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Michelle Reed arrived at facility the house to commence an announced Prelicensing visit. Upon arrival, LPA met with Cosmin Surgent. An initial application to operate an Residential Care Facility for the Elderly was submitted to the Central Applications Unit (CAU) on 4/2/21 for a capacity of 6 non-ambulatory residents of which 1 may be bedridden. The Anaheim Fire Department conducted a Fire Safety Inspection on 5/5/21 and granted a fire clearance. A tour of the physical plant was conducted inside and out at approximately 12:15am with Mr. Surgent and the following was observed:
Structure:
Facility is a one story house with 7 bedrooms and 4 bathrooms. Bedroom #1 through #6 are designated as resident rooms and are authorized for non-ambulatory resident use. Bedroom #6 will be the bedridden room and #7 will be for staff. There is also a living room, dining area and kitchen. The yard has a shaded area for residents to enjoy the outside and applicant will have patio furniture and a canopy for residents to enjoy.
Signal System:
Central air/heating system installed with a central panel to control entire house.
Bedrooms Residents:
The resident bedrooms( #1-#6) accommodate residents' furnishings and meet Title 22 regulation at this time. Bedrooms have slider doors and ramps to the outside.
Bathrooms:
4 bathrooms have a working toilet, wash basin, and shower. The 4th bathroom near the kitchen is for staff and visitors only. Grab bars and non-slip mats were observed in all.
Linens and Hygiene Supplies
Adequate supply of linens and hygiene items were observed
Ombudsman Poster, Personal Rights and See Something Say Something Poster
Applicant will request an Ombudsman poster. Personal Rights and See Something Say Something as well as the facility sketch were posted.
Food Service:
Adequate supply of 7-day non-perishable and 2 day perishables will be stored in the kitchen and pantry and will include fruits and vegetables. LPA observed non-perishables on today's visit..
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: AGAPE SENIOR II
FACILITY NUMBER: 306005993
VISIT DATE: 06/09/2021
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Smoke and Carbon Monoxide Detectors:
Smoke detectors and carbon monoxide systems were observed working at the time of this visit
Fire Extinguishers:
The fire extinguisher was mounted and fully charged at the time of this visit
Fire Clearance:
Approved on 5/5/21
Appliances:
Refrigerator/freezer and microwave which were clean and noted to be operational. Washer and dryer were clean noted to be operational.
Toxins/Sharps:
Will be locked and inaccessible to residents
Water Temperature:
Tested and recorded at 120 degrees F.
Medications, First Aid Kit & Manual:
First Aid kit with guide will be stored with resident medications. Medication will be stored and locked in the facility living area.
Resident and Staff Files:
Records will be kept locked for privacy
Component III
Component III was conducted

The Prelicensing is complete and this facility has no deficiencies.

The Licensee will be granted upon a final review by the Central Applications Bureau and approval by management.

An exit interview was conducted and a copy of this report was provided to Cosmin Surgent.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
LIC809 (FAS) - (06/04)
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