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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700806
Report Date: 08/25/2020
Date Signed: 08/25/2020 01:47:31 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:AGAPE VILLA CARE HOME IIFACILITY NUMBER:
312700806
ADMINISTRATOR:WONG, DARRELLFACILITY TYPE:
740
ADDRESS:3594 OLD COUNTRY COURTTELEPHONE:
(916) 993-3133
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 5DATE:
08/25/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Darrell Wong TIME COMPLETED:
01:50 PM
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On August 25, 2020 at 12:50pm, Licensing Program Analyst (LPA) Sarena Keosavang contacted the facility via telephone to commence an announced Pre-Licensing Tele-Inspection visit due to COVID-19 and pre-cautionary measures.

LPA was allowed entry into the facility via Facetime. LPA toured and inspected the indoor and outdoor premises of the facility with administrator, Darrell Wong, to ensure there are no health and safety concerns. Indoor and outdoor passageways were free of obstruction.

There are a total of six (6) bedrooms and six (6) bathrooms. LPA observed the kitchen area, living room, bedrooms, bathrooms, garage and dining room. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed two (2) residents' bedrooms that had an exit leading to the backyard. LPA observed a working alarm in both of the residents' bedrooms. LPA observed fire detectors and carbon monoxide present in all residents' bedrooms. Bathrooms are clean, sanitary, and in good repair. LPA observed food supplies of non-perishables for a minimum of one week and perishable foods for a minimum of two days. LPA observed knives/ sharps area were locked underneath the kitchen sink. Toxic and cleaning supplies locked in the laundry room. The hot water temperature was measured in the kitchen at 108 degrees Fahrenheit. First aid kit was completed. LPA observed centrally stored medications area were locked and inaccessible to residents in care. Licensing complaint poster are posted as required.

LPA reviewed the change of ownership application. LPA discovered that a follow up with CAB of correct LIC 200 is needed. LPA observed that the facility is ready to be licensed. This report will be submitted to the Central Applications Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

An exit interview was conducted with administrator, Darrell Wong, and a copy of this report will be provided to the facility via United States Postal Service and email. Two Copies will be sent to the facility, 1 is to be signed and returned to Community Care Licensing (CCL) and the other copy is to be retained by the facility.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2020
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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