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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317005164
Report Date: 11/02/2020
Date Signed: 11/02/2020 08:24:37 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/15/2020 and conducted by Evaluator Kevin Mknelly
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200415100722
FACILITY NAME:AGAPE VILLA CARE HOME IIFACILITY NUMBER:
317005164
ADMINISTRATOR:COOK, KEITHFACILITY TYPE:
740
ADDRESS:3594 OLD COUNTRY COURTTELEPHONE:
(916) 290-1490
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:0CENSUS: 0DATE:
11/02/2020
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Keith CookTIME COMPLETED:
08:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff not properly trained.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/2/20, Licensing Program Analyst (LPA) Kevin Mknelly communicated with Keith Cook, Licensee/ Administrator of facility Agape Villa Home Care II – 317005164 at approximately 9 AM.
This facility is currently closed due to change of ownership.

LPA reviewed client/resident records and conducted extensive interviews.
LPA finds that the allegations cited above are substantiated.

The complaint investigation was initiated on 4/18/20. Staff training records were received by LPA as provided by the facility manager on 6/19/20 for four current staff. Records provided indicated that four of four staff ( S1, S2, S3 and S4) did not have record of the required eight hours of annual continued medication training. H&S 1569.69 Employees assisting residents with self-administration of medication; training requirements (b)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20200415100722
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 II
FACILITY NUMBER: 317005164
VISIT DATE: 11/02/2020
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
26
27
28
29
30
31
32
Each employee who received training and passed the examination …, and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication related issues in each succeeding 12-month period. This requirement was not met based on records review and interviews. This posed a potential risk to residents.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Unable to obtain signature. Signature present on hard copy in file. LPA sent a copy of report to Licensee, Keith Cook, to sign. Administrator to send a signed copy back to CCL.
Additionally, LPA sent a copy of the appeal rights.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20200415100722
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 II
FACILITY NUMBER: 317005164
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/03/2020
Section Cited
HSC
1569.69(b)
1
2
3
4
5
6
7
 Employees assisting residents with ...medication; training requirements (b)Each employee who ... assist with the self-administration of medicines, shall also complete eight hours
1
2
3
4
5
6
7
The delivery of these findings were delayed by Govenor's order.
Prior to closure of this facility in change of ownership in September of 2020, the licensee corrected this deficency by providing
8
9
10
11
12
13
14
of in-service training on medication ... in each ... 12-month period. This requirement was not met based on records review and interviews. This posed a potential risk to residents.
8
9
10
11
12
13
14
the necessary training to staff who administer medications.

This deficiency is cleared.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3