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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006104
Report Date: 05/13/2024
Date Signed: 05/13/2024 03:49:08 PM

Document Has Been Signed on 05/13/2024 03:49 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:ST. AGNES HOME CARE, LLCFACILITY NUMBER:
306006104
ADMINISTRATOR/
DIRECTOR:		AGNES, DJHOANA Q.FACILITY TYPE:
735
ADDRESS:1019 S ADAMS AVENUETELEPHONE:
(657) 248-7304
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY: 4CENSUS: 3DATE:
05/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Administrator Reb AgnesTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 5/13/2024, Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced required visit using the CARE Inspection Tool. LPA was greeted by staff and granted entry after stating the purpose of the visit. Administrator (Admin) Reb Agnes was present to assist with the facility inspection on today's date.

The facility is licensed for four (4) ambulatory clients. Currently, there are three clients present during today’s visit.

This is a single story residential home with a two-car garage facility. The facility has five bedrooms, four client rooms and one staff room. Facility has two full bathrooms.

At around 12:40, LPA conducted a tour of the physical plant accompanied by Administrator Reb Agnes, and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 113.1 degrees F. A comfortable temperature of 74 degrees F. was maintained in the facility.



LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, toxins and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Facility has an adequate emergency food and water supply. Facility has one fire extinguisher that was mounted and fully charged. A review of the Medication Records Administration (MAR) was conducted, and LPA observed the records are in compliance.

CONTINUED ON 809C
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ST. AGNES HOME CARE, LLC
FACILITY NUMBER: 306006104
VISIT DATE: 05/13/2024
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents. LPA observed the facility has Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained along with a first aid manual. A working land line phone was operational. The last fire drill was conducted on 3/16/2024. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 7/15/23 - 7/15/2024. The facility is current on Community Care Licensing annual dues.

A review of three Clients (C1-C3) service files and three staff (S1-S3) personnel files revealed to be complete. The facility has the current administrator's certification on file for Reb Agnes # 7033914735 - Expiration 10/1/2025.

No deficiencies during this inspection visit.

An exit interview was conducted with Administrator Agnes, and a copy of the report was provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024
LIC809 (FAS) - (06/04)
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