306006104-5-20-2026-22-AS-NGUN-DU9PBA-20260520111001

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006104
Report Date: 05/20/2026
Date Signed: 05/20/2026 11:10:19 AM

Document Has Been Signed on 05/20/2026 11:10 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, LLC		FACILITY NUMBER:	306006104
ADMINISTRATOR/ DIRECTOR:	AGNES, DJHOANA Q.		FACILITY TYPE:	735
ADDRESS:	1019 S ADAMS AVENUE		TELEPHONE:	(657) 248-7304
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92832
CAPACITY: 4		CENSUS: 4	DATE:	05/20/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Reb Agnes		TIME VISIT/ INSPECTION COMPLETED:	11:25 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA) Nancy Guillen conducted this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by care provider Alberto De La Vega after explaining the purpose of the visit. Administrator (AD) Reb Agnes was notified via telephone and later arrived to assist with the inspection. LPA observed Administrator certificate is current with an expiration date of October 01, 2027 .This is an Adult Residential Facility licensed for four ambulatory clients with four clients residing at the facility Facility stays within the capacity limitations. LPA was notified that two clients were away at day program and LPA observed two clients were present at the facility during the visit. LPA began the tour of the inside and outside of the facility and observed the following: This is a one story facility with four client bedrooms, one staff room, two bathrooms, a living room, kitchen, laundry room, dining room, and an attached garage with an exterior entrance. LPA observed required department postings posted on the wall in the living/dining room of the facility. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food storage in the garage . The facility is maintained at a comfortable temperature. LPA observed that medication is centrally stored in a locked storage cabinet located in the laundry room. LPA reviewed medication and observed medication was labeled and stored inaccessible to clients in care. Continued on LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Nancy Guillen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/20/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2026

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: 05/20/2026

NARRATIVE

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Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 111.2 and 114.4 degrees Fahrenheit. All bathrooms observed to have a supply of soap, toilet paper and paper towels. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants stored under the kitchen sink and in a hallway closet next to the laundry room. The facility has an available clean supply of linens in a hallway storage cabinet. LPA inspected client’s bedrooms which have sufficient lighting to ensure safety and comfort. All bedrooms observed to have all required components. Storage space is provided for clients in their bedroom. Smoke detectors and carbon monoxide detector were tested and found to be operational.

LPA toured the outside of the facility and observed outdoor passageways were free of obstructions. LPA observed there was a shaded area outdoors for client use and outdoor furniture was temporarily placed in the garage. LPA observed a fire extinguisher with service date of December 8, 2025 in the laundry room, near the kitchen. Fire drills are conducted quarterly with the last drill conducted on March 6, 2026. LPA began review of records. LPA reviewed four client's records. All the required documentation was present and current in client's files reviewed. The facility P&I records were reviewed. LPA observed that an individual log is maintained for each client. All monies are accounted for and attached receipts for record keeping. LPA reviewed three employee records. All employees present have a criminal record clearance and are associated to the facility. LPA observed records reviewed have a current First Aid certificates.

Based on the observation made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the Administrator and a copy of this report and the Legionnaire's Disease Fact Sheet was provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Nancy Guillen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/20/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2026

LIC809 (FAS) - (06/04)

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