331881118-10-8-2021-18-AS-DMUN-C8T2LK-20211115162936

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881118
Report Date: 10/07/2021
Date Signed: 10/08/2021 11:58:06 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/06/2021 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20211006095731

FACILITY NAME:	AGAPE VILLA		FACILITY NUMBER:	331881118
ADMINISTRATOR:	HUNG, MARIE		FACILITY TYPE:	740
ADDRESS:	7027 GOLDEN VALE DRIVE		TELEPHONE:	(951) 255-1198
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92506
CAPACITY:	6	CENSUS: 4	DATE:	10/07/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Marie Hung, Administrator		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Facility is not screening visitors before entering facility.
Visitors are not wearing masks in facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to initiate the investigation into the above allegations. The LPA met with Administrator, Marie Hung, and informed her of the purpose of the visit.

Pertaining to the allegation, "Facility is not screening visitors before entering facility," it was alleged facility staff are not screening visitors for COVID-19 prior to entry. On this visit the LPA conducted staff/resident interviews, reviewed records, obtained copies of pertinent information, and toured the facility. The LPA observed a screening station available at entry, with hand sanitizer, a sign-in sheet, and thermometer available. The LPA did not observe a COVID-19 symptoms questionnaire available at time of visit, however, the Administrator reported it is done verbally with visitors. Resident interview did not corroborate or refute the validity of the violation. Therefore, based on insufficient information this allegation is deemed UNSUBSTANTIATED at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20211006095731

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: AGAPE VILLA	FACILITY NUMBER: 331881118
	VISIT DATE: 10/07/2021

NARRATIVE

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Regarding the allegation, "Visitors are not wearing masks in facility," it was alleged visitors are permitted in the facility without a mask. One visitor was observed present at time of visit and was wearing a mask. Administrator Hung denied the allegation. Interviews reported no one is permitted in the home without a mask and are offered one if they do not have one available. Due to a lack of information, this allegation is deemed UNSUBSTANTIATED at this time.

A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

This report was reviewed with Hung and a copy provided.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

LIC9099 (FAS) - (06/04)

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