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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881219
Report Date: 01/18/2022
Date Signed: 03/02/2022 01:13:11 PM


Document Has Been Signed on 03/02/2022 01:13 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 01/24/2022 10:24 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

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*THIS IS AN AMENDED REPORT

Licensing Program Analyst (LPA) Amy Goldenberg conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Unit (CAU) on 08/20/2021 for a total capacity of four (4) non-ambulatory residents and one (1) bedridden resident in bedrooms 1 or 3 only. Fire Clearance was granted 09/15/2021 LPA Goldenberg observed the following:

Structure: Facility is a two (2) story house with three (3) resident bedrooms on the first floor, two bathrooms, living room, dining area, and kitchen area.

Heating/Cooling System: Central heating and air conditioning systems.

Bedrooms: Each resident bedroom will accommodate Non-Ambulatory clients. All bedrooms were adequately furnished with bed, chair, large closets, appropriate linens, adequate lighting, and an operational smoke alarm.

Bathrooms: Bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. Water temperature measured by LPA at 108 F.

Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies and knives/sharp instruments were secured in a locked cabinet and/or drawer. There was adequate room for food storage. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2022
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AGAPE HOME FOR THE ELDERLY
FACILITY NUMBER: 331881219
VISIT DATE: 01/18/2022
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Living/Family room: Furnished with safe and adequate seating and furnishings. All items appear to be in good repair.

Yards/Outside: The back was completed was a patio with adequate covered area for providing shade. There were no obstructions. There is a pool secured with a locked perimeter.

Garage: Laundry area with washer and dryer were located near the garage entrance. Laundry detergents and cleaning solutions were secured behind a locked cabinet door. Garage was organized and free of obstructions. Additional freezer and refrigerator are located in the garage.

Emergency Phone Numbers, and Exit Plan: Let-Us-No poster, Ombudsman poster and clients rights are posted.

General items: The facility phone was verified to be operational by LPA.

LPA reviewed COMPONENT III with the applicant during this Pre Licensing Inspection.

This facility physical plant is prepared for licensure at this time.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022
LIC809 (FAS) - (06/04)
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