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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700806
Report Date: 08/08/2023
Date Signed: 08/08/2023 04:04:15 PM


Document Has Been Signed on 08/08/2023 04:04 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 IIFACILITY NUMBER:
312700806
ADMINISTRATOR:WONG, DARRELLFACILITY TYPE:
740
ADDRESS:3594 OLD COUNTRY COURTTELEPHONE:
(916) 993-3133
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 6DATE:
08/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Administrator: Joanne Nebeker TIME COMPLETED:
04:10 PM
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
On 08/08/2023 at 1:35 PM, Licensing Program Analyst (LPA) Sarena Keosavang and Staff Service Manager (SSM) III, Thea Perrino arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA met with administrator, Joanne Nebeker, and explained the purpose of the visit.

At 1:40 PM, LPA, SSM, ED toured the interior and exterior of the facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, residents' bedrooms, bathrooms, kitchen, courtyard, medication rooms, and backyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed residents' bathrooms to be clean, sanitary, and in good repair. LPA observed pool in the backyard is locked and inaccessible to residents in care. LPA observed food supplies of non-perishables for a minimum of one (1) week and perishable foods for a minimum of two (2) days. Toxic and cleaning supplies locked and is inaccessible to residents in care. The hot water temperature was measured in the kitchen at 106 degrees Fahrenheit. LPA observed fire detectors and carbon monoxide alarms to be operable. LPA observed medications to be locked and inaccessible to residents in care. LPA observed required Licensing posters posted throughout the facility.

At 2:00 PM, LPA reviewed a total of six (6) resident files. Resident files contain signed admission agreements, physician's reports, appraisals, identification sheets, and resident's rights. Medications are centrally stored, locked, and appear to be given per doctor order. Facility is correctly using the Medication Administration Records (MAR). LPA reviewed a total of four (4) staff record. Staff has training in medications, first aid and CPR, and other various areas of care provision.

No deficiencies being cited as of today's visit.

Exit interview conducted and report provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2023
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 3