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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700804
Report Date: 09/30/2021
Date Signed: 09/30/2021 02:27:45 PM

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:
09/30/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Darrell Wong, AdministratorTIME COMPLETED:
02:45 PM
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Licensing Program Analysts (LPA)Bethany Mirlohi and Jacob Williams conducted a case management visit to the facility on today's date for the purpose of delivering an Order To Individual of Immediate Exclusion from all facilities and the Order to Licensee/Facility of Immediate Exclusion From Facility. 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. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Masks. Additionally, LPA was screened by staff upon entering the facility.

LPAs met with Administrator, Darrell Wong and explained the purpose of today's visit. Staff, Kandice Taylor, is excluded as a result not related to this facility. LPAs Mirlohi and Williams handed the Order to Licensee/Facility of Immediate Exclusion From Facility letter to Darrell Wong and explained that staff, Kandice Taylor is not allowed back at the facility.

A copy of this report was provided to Administrator.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
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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