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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006104
Report Date: 05/20/2025
Date Signed: 05/20/2025 10:46:35 AM

Document Has Been Signed on 05/20/2025 10:46 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
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:
05/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Marilyn Balmes TIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Marilyn Balmes and informed them of the purpose of the inspection. The facility currently has three clients of which two were seen getting ready for day program and one was sleeping.

The facility is a one story home with four client bedrooms, two bathrooms, one staff bedroom, a kitchen, living room, dining area, laundry room, and attached two car garage. The facility appears clean, safe, and sanitary. LPA observed the client bedrooms to have all the required components and furnishings. LPA observed the bathrooms to have toilet paper, paper towels, and non-slip mats. LPA tested the water in the bathrooms to be between 113 and 116 degrees Fahrenheit. LPA observed clean linens in a hall cabinet located by three of the client bedrooms. LPA observed the kitchen to be clean and free of debris and vermin. LPA observed the two day perishable and seven day non-perishable food supply on hand. LPA observed the knives and sharps to be locked in a drawer located by the kitchen sink and made inaccessible to clients in care. LPA observed toxins to be in a locked cabinet under the kitchen sink and made inaccessible to clients in care. LPA observed a fire extinguisher in the laundry room to be charged and with a service date of January 22, 2025. LPA observed the centrally stored medication to be stored in a locked cabinet located in the laundry room and made inaccessible to clients in care. LPA observed the staff bedroom locked and made inaccessible to clients in care. LPA observed all appliances to be in working condition. LPA observed the emergency food and water supply located near the staff bedroom. LPA observed the backyard to be free of obstructions and had a shaded seating area for client use. LPA observed the garage to be locked making it inaccessible to clients in care. LPA observed that the garage had an extra fridge and freezer for food storage. LPA observed shelves for extra food storage located in the garage.

Continue on 809-C

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Hanna Gough
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 05/20/2025
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 LPA observed the staff and client files were stored in cabinets located in the garage. LPA observed extra toxins and chemicals stored in the garage making them inaccessible to clients in care. LPA tested the smoke and carbon monoxide detectors, and they were found to be operational.

LPA reviewed staff files, no discrepancies were observed. LPA reviewed client files, no discrepancies were observed. LPA reviewed P & I with AD and no discrepancies were observed. LPA reviewed client medications, and no discrepancies were observed. LPA observed the last fire drill to be conducted on March 17, 2025.

Based on today’s inspection no deficiencies were noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Marilyn Balmes and a copy of this report was given at the time of inspection.

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Hanna Gough
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
LIC809 (FAS) - (06/04)
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