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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005993
Report Date: 06/22/2022
Date Signed: 06/22/2022 12:08:05 PM


Document Has Been Signed on 06/22/2022 12:08 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
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: 6DATE:
06/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Edy Wibowo, Fnu Siska, Cosmin Surgent TIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with staff Edy Wilbowo and Fnu Siska and stated the purpose of this visit. Administrator Cosmin Surgent arrived during the inspection and provided assistance.

The facility is a single level structure and licensed for five non-ambulatory and one bedridden of which three can be on hospice. This facility offers Residential Care for the Elderly.

At about 9:55 am, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed four clients in care and two staff members on duty. LPA Tapia reviewed Facility Personnel Report and noticed that staff Edy Wibowo, Fnu Siska are not associated with the facility. LPA Tapia informed Administrator that all staff need to be associated to the facility. Administrator provided proof of paperwork sent for association. LPA Tapia was provided copies of paperwork sent for association. LPA toured the interior and exterior portions of the facility. There were six resident rooms one of which was a shared resident room and one room for caregivers only. Resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide, and auditory exit alarms were tested to be operational. Bathroom (1) was observed to be in good repair and provided with grab bars and hot water was measured at 116.7 degrees Fahrenheit. Bathroom (2) was observed to be in good repair and provided with grab bars and hot water was measured at 116.6 degrees Fahrenheit. Facility met the minimum two day supply of perishable and seven day supply of non-perishable food stock requirements, cleaning supplies and sharp items were inaccessible to residents in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was observed to be charged and operational. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. The backyard also contained an operational washer/dryer.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward TapiaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022
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: 06/22/2022
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Facility also had a two-car garage which is used for storage, emergency supplies and equipped with an operational washer/dryer. Kitchen was in good repair with knifes and cleaning supplies kept locked. LPA Tapia reviewed the COVID 19 mitigation plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed. No citation was issued. Two advisories were issued today.

LPA Tapia conducted an exit interview with Administrator Cosmin Surgent and copy of this report was explained and left at the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward TapiaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC809 (FAS) - (06/04)
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