312700806-9-10-2024-59-AS-DAWL-D8YSXP-20240910141615

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 312700806
Report Date: 09/10/2024
Date Signed: 09/10/2024 02:16:26 PM

Document Has Been Signed on 09/10/2024 02:16 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	AGAPE VILLA CARE HOME II		FACILITY NUMBER:	312700806
ADMINISTRATOR:	WONG, DARRELL		FACILITY TYPE:	740
ADDRESS:	3594 OLD COUNTRY COURT		TELEPHONE:	(916) 993-3133
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95661
CAPACITY:	6	CENSUS: 6	DATE:	09/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Jo Nebeker, Administrator		TIME COMPLETED:	02:41 PM

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On September 10, 2024, Licensing Program Analyst (LPA) De Anna Williams-Lyons arrived unannounced to conducted an Annual Inspection of the facility to ensure compliance with Title 22 regulations. LPA Lyons met with Jo Nebeker, Administrator, who assisted LPA in today’s inspection. The Administrator certificate expires 8/6/2025. The current census is 6. The facilities Administrator’s Certificate, Emergency Disaster Plan, Resident’s Rights and Facility Sketch was available for viewing. The room temperature was 74 degrees F which is within range.

LPA inspected the interior and the exterior of the facility including the common living spaces, the kitchen, resident bedrooms and bathrooms. In the kitchen area, cabinets and drawers were reviewed. Knives and sharp objects were reviewed to make sure that they were locked and made inaccessible to the residents at all times. LPA observed there to be a sufficient amount of 2-day perishable and 7-day non-perishable food. Hot water temperatures were taken and measured at 105 degrees F, which is within the allowed range of 105-120 degrees. There’s appropriate lighting throughout the facility.

The facility is a one-story home with 6 bedrooms. Living rooms, dining room, and areas designated for resident use were toured. Furniture and furnishings were observed to be sufficient and in good repair. Resident bedrooms and bathrooms were toured. All rooms had the required items of furniture. Window screens were on and in good repair. Bathrooms were clean, sanitary and odorless and consisted of grab bars and non-skid mats. Hot water temperature is 105 degrees F. The sink, toilet, bathtub and shower operate properly. The facility has a sufficient supply of linens, towels, bedding, etc. for residents in care. Washer and dryer was present and operating properly. Toxic substances, laundry and cleaning supplies were inaccessible.

To continue see 809 C...

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: AGAPE VILLA CARE HOME II	FACILITY NUMBER: 312700806
	VISIT DATE: 09/10/2024

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First aid kit was present and included the required scissors, tweezers, thermometer and guide. Fire alarms, smoke alarms, and carbon monoxide detectors operate properly. Fire extinguisher is maintained and ready for emergency use. The facility was observed to have been annually inspected on August 5, 2024 by Fire Code and in compliance at this time. LPA inspected the exterior grounds of this facility. There are bodies of water on the premises. The pool's gate is double locked. The perimeter fence, side gates, and latches were in good repair. Passageways are free of obstruction and potential hazards.

There’s a centralized storage area for resident’s medication. Medication cabinet was locked. The facility Medication Administration Record was reviewed as well as the dispensing log. It was up to date and complete.

LPA reviewed 2 resident files and 2 staff files. Resident's Records reviewed indicated emergency contacts, Assessments, Admission Agreements and Physician's Reports were all current and up to date. Staff records reviewed revealed current First Aid & CPR certificates, Health Screenings and Emergency Contacts were all up to date and the facility is conducting staff training as required. The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610D the Emergency Disaster Plan, and copy of current Liability Insurance to update the facility file. Administrator shall submit the listed documents to Licensing no later than October 10, 2024.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies were observed today.

A copy of this report was left with Jo.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

LIC809 (FAS) - (06/04)

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