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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881118
Report Date: 07/03/2023
Date Signed: 07/03/2023 03:14:42 PM


Document Has Been Signed on 07/03/2023 03:14 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:AGAPE VILLAFACILITY NUMBER:
331881118
ADMINISTRATOR:HUNG, MARIEFACILITY TYPE:
740
ADDRESS:7027 GOLDEN VALE DRIVETELEPHONE:
(951) 255-1198
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY:6CENSUS: 6DATE:
07/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Licensee Marie Hung TIME COMPLETED:
03:30 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 7/3/2023, at 2:00 p.m., Licensing Program Analyst (LPA) Janette Romero arrived unannounced to conduct an annual required visit at the facility. LPA was greeted and granted entry by Caregiver Jocelyn Chua who was informed of the purpose of visit. At the time of visit there was six (6) residents and two (2) staff present. During the visit, Licensee Marie Hung arrived at the facility. LPA toured the facility’s interior and exterior, reviewed facility documents and conducted staff interviews. LPA observed residents in their rooms and common areas.

The facility is made up of a one-story home with five (5) resident bedrooms, (3) full bathrooms and a half bath along with an attached garage, and swimming pool in the backyard. The Residential Care Facility for the Elderly is approved for four (4) ambulatory and two (2) non-ambulatory residents. Facility has a hospice waiver for two (2) residents.

LPA observed the following:

Physical Plant: LPA toured resident and staff bedrooms. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair. The outdoor area was observed to be free of hazards. LPA observed swimming pool in the backyard, which was fenced. LPA observed outdoor furniture and shaded area available for residents. Laundry equipment was observed to be in working condition.



Continued on LIC809-C..
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2023
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AGAPE VILLA
FACILITY NUMBER: 331881118
VISIT DATE: 07/03/2023
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
Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility had four (4) refrigerators full of perishable food items and a pantry filled with non-perishable food items. Knives and sharps were secured in kitchen cabinets and inaccessible to residents.

Care & Supervision/Administration: LPA reviewed three (3) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Long-Term Care Ombudsman information, facility sketch, exit routes, personal rights information and emergency phone numbers were found posted in the facility. All resident medication was secured in a locked cabinet in hallway. Cleaning solutions were secured in a locked hallway closet.

Deficiencies: No deficiencies were observed at the time of the visit.



An exit interview was conducted where a copy of this report was discussed and provided to Licensee Hung.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2