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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006104
Report Date: 04/18/2022
Date Signed: 04/18/2022 01:23:59 PM

Document Has Been Signed on 04/18/2022 01:23 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:ST. AGNES HOME CARE, LLCFACILITY NUMBER:
306006104
ADMINISTRATOR:AGNES, DJHOANA Q.FACILITY TYPE:
735
ADDRESS:1019 S ADAMS AVENUETELEPHONE:
(562) 858-6185
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY: 4CENSUS: 0DATE:
04/18/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Administrators, DJhoana Agnes, Reb Agnes, and Marilyn BalmesTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Jenifer Tirre visited this facility for the purpose of conducting a Pre-Licensing evaluation. No Clients in care during time of visit. Facility is a single story residential home. LPA along with Administrators DJoana Agnes, Reb Agnes, and Marilyn Balmes toured facility.

Fire clearance approval was received on 02/03/21. Structure: Facility is a one story, 5 bedroom (4 Client rooms 1 staff room) 2 bathroom house with an attached garage with separate entrance through exterior. Home has a ivory exterior. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: All clients bedrooms meet Licensing requirements. Bathrooms: All resident bathrooms have a working toilet, wash basin, and bathtub/shower as well as non-skid surface in the shower. Linens & Hygiene Supplies: Facility has adequate supply of linens and towels. Emergency Phone Numbers and Exit Plan: Facility has Emergency Plan provided and facility sketch posted. Food Service: Facility has 7 day non-perishables in the pantry. Facility has small supply of perishable foods. Perishables to be provided once facility receives clients. Emergency food and water supply on hand. Smoke Detectors: Smoke detectors/ carbon monoxide detector are centrally wired and were tested operational. Fire extinguisher is mounted and charged. Facility has 1 extinguisher. Facility has audible alarms on all sliding windows and entrance/exit doors. Appliances: Stove and refrigerator are operational. Toxins: LPA observed toxins secured in locked location. Water Temperature: Tested and recorded between 107.7 to 111.9 degrees F. in facility bathrooms. Reading Material Games, and Equipment:
facility has Karaoke machine. Medications, First-Aid Kit & Book: Facility has first aid kit present at the facility. Facility has a secured location for medications and facility files. Backyard: LPA observed the facility perimeter is secured by wall with a self latching gate on one side of facility as required. LPA observed shaded outdoor seating.
CONTINUED ON 809C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2022
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: ST. AGNES HOME CARE, LLC
FACILITY NUMBER: 306006104
VISIT DATE: 04/18/2022
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Administrator's Certificate observed expiring on 10/1/ 2023.

Component III Orientation was conducted during this pre-licensing visit.


Licensee to address the following corrections by 4/25/2022:
  • First Aid manual
  • Emergency Flashlights with batteries
  • activity games and reading material
  • Department Postings on designated wall
  • Let Us Know Poster proper size 20x26 posted near entrance


The facility is not ready to be licensed. Licensee to contact LPA when corrections are complete.


An exit interview was conducted with Administrator and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022
LIC809 (FAS) - (06/04)
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