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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006104
Report Date: 04/25/2022
Date Signed: 04/25/2022 09:28:45 AM

Document Has Been Signed on 04/25/2022 09:28 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
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:
(657) 248-7304
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY: 4CENSUS: 0DATE:
04/25/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:54 AM
MET WITH:Administrator, Marilyn BalmesTIME COMPLETED:
09:40 AM
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Licensing Program Analyst (LPA) Jenifer Tirre made an announced pre-licensing visit to follow up on corrections identified during visit on 04/18/2022. LPA identified themselves and discussed the purpose of the visit with Administrator Marilyn Balmes. An initial application to operate a Adult Residential Facility was submitted to CCL on 11/04/2021. There are 0 residents in care during today's visit.

At 9:02 AM LPA toured the facility and observed the following:

· Facility obtained First Aid Manual for First Aid Kit

· Facility obtained emergency flashlights and batteries

· Facility has supplied activity board games, outdoor equipment and ample reading material

· Facility has designated wall that contains Department postings

· Let Us Know Poster is proper size 20x26 posted near entrance


All noted items from visit on 04/18//2022 have been addressed.
The facility is ready to be licensed.

An exit interview was conducted with Administrator Marilyn Balmes and a copy of this report was left at the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2022
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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