<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006432
Report Date: 05/03/2024
Date Signed: 05/03/2024 12:11:29 PM

Document Has Been Signed on 05/03/2024 12:11 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 2FACILITY NUMBER:
306006432
ADMINISTRATOR/
DIRECTOR:		AGNES, DJHOANAFACILITY TYPE:
735
ADDRESS:112 S KINGSLEY STTELEPHONE:
(562) 715-8869
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY: 4CENSUS: 0DATE:
05/03/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:11 AM
MET WITH:Licensee Djhoana AgnesTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
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's) Jenifer Tirre and Michael Tea made an announced pre-licensing visit. LPA's identified themselves and discussed the purpose of the visit with Licensee/Administrators Djhoana Agnes, Reb Agnes, and Marilyn Balmes. An initial application to operate a Adult Residential Facility was submitted to CCL on 9/18/2023. There are 0 clients in care during today's visit.

LPA's Tirre and Tea along with Licensee Agnes and Administrators Agnes & Balmes toured the facility at 9:26 AM and observed the following:
Structure: Facility is a one story, 5 bedroom (4 clients bedrooms and 1 live in staff bedroom) 3 bathroom house with attached garage and a blue 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 client 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 posted on wall. Food Service: Facility has 2 day perishables as well as 7 day non-perishables in the pantry/ refrigerator, as well as adequate emergency food and water supply. Smoke Detectors: Smoke detectors/ carbon monoxide detector are centrally wired and were tested operational. Facility has one Fire extinguisher that is mounted and charged. Facility has audible alarms on all sliding/exit doors. Appliances: Gas Stove, microwave, refrigerator, washer and dryer are operational. Toxins: LPA's observed toxins secured in laundry storage area.. Water Temperature: Tested and recorded between 108.8 to 124.1 degrees F. in facility bathrooms. Reading Material Games, and Equipment:
facility has puzzles, games, and sporting equipment. Facility has I-Pad device with access to internet for clients use Medications, First-Aid Kit & Book: Facility has first aid kit & First aid handbook present at the facility.

CONTINUED ON 9099C

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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 2
FACILITY NUMBER: 306006432
VISIT DATE: 05/03/2024
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
26
27
28
29
30
31
32
Facility has a secured location for medications and facility files. Backyard: LPA's observed the facility perimeter is secured by wall with a self latching gate on right side of facility as required. LPA's observed shaded outdoor seating.

Administrator's Certificate observed on wall for Djhoana Agnes expiring October 1, 2025



Component III Orientation was waived during this pre-licensing visit due to Licensee presently operating another facility.

No deficiencies noted during todays visit. The pre-licensing visit has been completed. This location is ready for licensure.


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

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2