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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700804
Report Date: 06/08/2021
Date Signed: 07/09/2021 10:20:39 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:AGAPE VILLA CARE HOME IFACILITY NUMBER:
312700804
ADMINISTRATOR:WONG, DARRELLFACILITY TYPE:
740
ADDRESS:1105 NOB HILL COURTTELEPHONE:
(916) 993-3133
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 6DATE:
06/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Alex Bober, Operations ManagerTIME COMPLETED:
11:30 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 Analyst (LPA) Williams arrived at the facility unannounced on 06/8/2021 to conduct a Required 1- Year Inspection utilizing the infection control domain. LPA met with Operations Manager, Alex Bober, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPA ensured he applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by facility staff upon entering the facility.

LPA and staff toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, six (6) resident bedrooms, two (2) bathrooms, kitchen, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and administrator completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report left at the facility.

(facility phone number has changed to 916 755 4664)

(Old Counrty/Agape Villa Care Home II phone number has changed to 916 474 4363)

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021
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 1