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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700806
Report Date: 03/09/2021
Date Signed: 03/09/2021 02:02:17 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:
03/09/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:37 PM
MET WITH:Joanna NebkeerTIME COMPLETED:
02:05 PM
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On March 9, 2021 at 2:00 PM, Licensing Program Analyst (LPA) Sarena Keosavang contacted the facility and spoke with House Manager, Joanna Nebkeer, via telephone to conduct an unannounced Case Management- Incident to obtain additional information regarding an incident that occurred on 2/20/2021 and 2/21/2021. This visit was conducted via telephone due to COVID-19 and precautionary measures.

The purpose of the telephone call was to follow-up on an Unusual Incident Report that was submitted to Community Care Licensing (CCL). On 2/20/2021, this report indicated resident (R1) had a fall and a minor skin tear. On 2/21/2021, R1 lost balance and fell backward. R1's head had hit the side table. Paramedics were called and R1 was sent to the hospital for evaluation. R1 had returned back to the community a few hours later.

LPA interviewed Joanna regarding the incident report. The interview with Joanna indicates that R1 had returned back to the community and is doing well. LPA requested for R1's physician's report, care plan, and discharge medical documents.

At this time, deficiencies are not being cited.

A copy of this report has been emailed to the facility and the House Manager, Joanna Nebkeer, was advised that a signed copy of the report shall be emailed to LPA.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021
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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