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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412239
Report Date: 12/20/2022
Date Signed: 12/20/2022 01:02:55 PM


Document Has Been Signed on 12/20/2022 01:02 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:AGAPE CARE HOME RIVERSIDEFACILITY NUMBER:
336412239
ADMINISTRATOR:DARYL LEEFACILITY TYPE:
740
ADDRESS:5715 RIVERSIDE AVENUETELEPHONE:
(951) 682-1389
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY:6CENSUS: 6DATE:
12/20/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Daryl Lee, LicenseeTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Jesse Gardner and Jackie Shaw-Ross arrived at the facility unannounced in reference to complaint 18-AS-20221214110031. LPAs met with Licensee Daryl Lee and explained the purpose of the visit.

During the tour of the facility, LPAs noted medication that was being pre-poured and stored in plastic cups. When asked, LPAs were told that Administrator Matthew Olea does the medication, and has been doing so for at least a year. Licensee advised they will discontinue pre-pouring medications. Deficiency cited.

LPAs also found Caregiver Josie Perez to not have a background clearance. Deficiency cited.

An exit interview was conducted, and a copy of this report was discussed along with copies of the LIC809-D, LIC421BG, and Appeal Rights were provided.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022
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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Document Has Been Signed on 12/20/2022 01:02 PM - It Cannot Be Edited

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 CARE HOME RIVERSIDE
FACILITY NUMBER: 336412239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/21/2022
Section Cited

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Criminal Record Clearance:
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

(1) Obtain a California clearance or a criminal record exemption as required by the Department or
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Licensee agrees to immediately remove S1 from the facility, and obtain a background clearance prior to S1 working in the facility. Licensee to provide proof of submission of background clearance to LPA by POC date. LPAs observed S1 leaving property.
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Based on LPA's record review, and interview, LPA found that S1 did not have a background clearance. Licensee did not follow regulation. This is an immediate health and safety and personal rights risk to residents in care.
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Type B
01/03/2023
Section Cited

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Incidental Medical and Dental Care: (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
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Licensee agrees to discontinue pre-pouring medication, and submit an in-service training of all staff on how to manage medications by POC date.
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Based on LPA observation of pre-poured cups containing an assortment of medication, Licensee did not follow the regulation. This poses a potential health and safety and personal rights risk to residents in care.
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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: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022
LIC809 (FAS) - (06/04)
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