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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530180
Report Date: 05/13/2024
Date Signed: 05/13/2024 11:28:51 AM

Document Has Been Signed on 05/13/2024 11:28 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:AGAPE RESIDENTIAL HOME LLCFACILITY NUMBER:
335530180
ADMINISTRATOR/
DIRECTOR:		BAIZA, HELEN MARLENEFACILITY TYPE:
735
ADDRESS:3057 NORELLE DRIVETELEPHONE:
(909) 226-9739
CITY:JURUPA VALLEYSTATE: CAZIP CODE:
91752
CAPACITY: 4CENSUS: 0DATE:
05/13/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:17 AM
MET WITH:Helen Baiza - Administrator TIME VISIT/
INSPECTION COMPLETED:
11:35 AM
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Licensing Program Analysts (LPAs) Magda Malcore and Sarina Ramirez conducted an announced visit to complete the Pre-licensing inspection. LPAs met with Helen Baiza, Administrator, and discussed the purpose of the visit. An initial application to operate an Adult Residential Facility (ARF). A fire clearance was granted by the Riverside County Fire Department on 12/08/23 for a total capacity of (4) ambulatory clients. LPAs observed the following:

Physical Plant: Indoor and outdoor passageways are free of obstruction. The facility has no swimming pools or similar bodies of water. The facility window screens were observed to be in good repair. The facility has sufficient shaded outdoor space and sufficient indoor space for client activities. The facility has sufficient lighting and is maintained at a comfortable temperature. The facility has operating telephone service, smoke/carbon monoxide alarms, and laundry equipment. The facility has posted in a common area, emergency exiting plan, facility visiting policy, Individual personal rights, Community Care Licensing Complaint poster, and a space for client counsel meetings. Sharps were kept locked under the kitchen sink.

Bedrooms/Bathrooms: Client bedrooms are equipped with mattresses, bed linen, pillows, chairs, dressers, nightstands, and sufficient lighting. Client bathrooms are clean and equipped with nonslip mats, covered waste bins, and operating toilets, washbasins, showers. The hot water temperature measured 109.5 and 115 degrees F. A night light was observed in the hallway area outside of client bathroom.

Food Service: The kitchen and dining areas are maintained clean. The facility has an adequate number of cups, dishes, and utensils for client use. The facility has a sufficient seven (7) day supply of non-perishable foods. The two (2) refrigerators and freezers have sufficient space for at least two (2) days of perishable foods.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2024
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AGAPE RESIDENTIAL HOME LLC
FACILITY NUMBER: 335530180
VISIT DATE: 05/13/2024
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Medications: The facility has a designated locked cabinet for client medications.

Supplies: The facility has sufficient supply of clean bed linen, bath towels, paper towels, personal hygiene products, client activity items, emergency flashlights and first-aid.

Records: The facility has a designated storage area for client and staff files.

Overall, the facility is clean and in good repair. The Prelicensing inspection and the Comp III orientation are complete; no corrections are required.



An exit interview was conducted where this report was discussed and a copy of this report was provided to the Administrator at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024
LIC809 (FAS) - (06/04)
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