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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412239
Report Date: 01/12/2023
Date Signed: 01/12/2023 05:04:48 PM


Document Has Been Signed on 01/12/2023 05:04 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: 5DATE:
01/12/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
04:12 PM
MET WITH:Kashmir Singh, CaregiverTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced case management visit to follow up on a Plan of Correction that has not been received by the Department. LPA met with Caregiver Kashmir Singh and toured the facility.

The initial Plan of Correction was issued on 12/20/2022 for a citation of CCR 87465(h)(5) Incidental and Medical Care. This citation was in reference to not storing medication in its original prescribed container. On today's date while conducting a tour of the facility, LPA noted that the Licensee has since discontinued pre-pouring medications (not storing them in their prescribed container).

At the time of original visit on 12/20/2022, concluding the citation, Licensee agreed to provide LPA in-service training of all staff on how to manage medications by POC date, which was 1/3/2022. Additionally, LPA spoke with Licensee via telephone 1/9/2023, and Licensee ensured that POC would be completed and sent. An official extension was not received nor requested by Licensee. As of this date, POC has yet to be complete.

Due to the POC not being corrected at the requested amount of time, a civil penalty was issued.

An exit interview was conducted where a copy of this report was discussed and provided to Licensee Daryl Lee along with a copy of the LIC421FC, and Appeal Rights.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023
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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