336412239-8-11-2023-18-AS-JDHS-D36NCT-20240308092112

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336412239
Report Date: 08/11/2023
Date Signed: 08/11/2023 03:35:55 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/14/2022 and conducted by Evaluator Venus Mixson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20221214110031

FACILITY NAME:	AGAPE CARE HOME RIVERSIDE		FACILITY NUMBER:	336412239
ADMINISTRATOR:	DARYL LEE		FACILITY TYPE:	740
ADDRESS:	5715 RIVERSIDE AVENUE		TELEPHONE:	(951) 682-1389
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92506
CAPACITY:	6	CENSUS: 6	DATE:	08/11/2023
		UNANNOUNCED	TIME BEGAN:	03:29 PM
MET WITH:	ADMINISTRATOR, DARYL LEE		TIME COMPLETED:	03:36 PM

ALLEGATION(S):

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Staff are not able to meet resident's medication needs.
Licensee not providing activities for residents.
Facility oven is broken.
Staff not following prescription orders.
Staff neglected resident who fell.
Staff not showering residents according to Admission Agreements.

INVESTIGATION FINDINGS:

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On August 11, 2023, Licensing Program Analyst (LPA), Venus Mixson conducted a visit to the facility and met with the Administrator. The visit was conducted in order to provide the findings for the investigation pertaining to the listed allegations. During the investigation, LPA Mixson conducted interviews with the Licensee, Administrator, and staff and residents.

On December 14, 2022, Community Care Licensing (CCL), received information stating the facility staff are not able to meet the resident's medication needs, the Licensee is not providing activities for the residents, the facility oven is broken, staff are not following the prescription orders, staff neglected resident who fell, and staff are not showering residents according to the admission agreements.

Regarding the allegation, staff are not able to meet the residents medication needs, the information obtained from interviews and the record review, revealed the facility staff are able to meet the resident's medication needs. The residents medication records (MARS), did not reveal the staff are not able to meet the residents medications needs. The interviews and the record review does not corroborate the listed allegation.

CONTINUED ON 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus Mixson	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 18-AS-20221214110031

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 08/11/2023

NARRATIVE

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Regarding the allegation, Licensee is not providing activities for the residents, the information obtained from interviews and the record review demonstrated the Licensee is providing activities for the residents. The Information obtained from interviews stated the residents have the right to refused to participate in an activity, and/or to participate in the activities of their choice.

Regarding the allegation, the facility is not clean, the information received from interviews, and observations disclose the facility was clean at the time of the investigation. The interviews and the observations do not validate the listed allegation.
Regarding the allegation, the facility oven is broken, the evidence obtained from interviews, and observations, does not support the allegation.
Regarding the allegation, staff are not following prescription orders, the evidence received from interviews and the record review does not verify the listed allegation. Review of the resident’s medical administration report (MARs) does not validate the allegation. The record review shows the staff are following the prescription orders.
Regarding the allegation, Staff not showering residents according to admission agreements, the information gathered from interviews and the record review do not support the listed allegation. The evidence shows the residents are being showered according to the resident's admission agreements, and the resident has the right to refuse any service. The interview with S2 stated that R1 was showered once or twice a week and if R1 refused the shower R1 was given a sponge bath.
Regrading the allegation, Staff neglected resident who fell, the information obtained through interviews and the record review proved there was not sufficient evidence to determine if staff neglected a resident who fell.

Regarding the allegation, Licensee not reporting incidents to Licensing, the information obtained from interviews and the records reviewed do not support this allegation.
CONTINUED ON 9099-C

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus Mixson	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 18-AS-20221214110031

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 08/11/2023

NARRATIVE

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Based on interviews and record reviews the information obtained did not corroborate the listed allegations. There was not sufficient evidence to support the listed allegations, therefore these allegations have been deemed "UNSUBSTANTIATED." An allegation finding of unsubstantiated means "although the allegation may have happened, or is valid there is not a preponderance of the evidence strand to prove the alleged violation did or did not occur.

An exit interview was conducted and a copy of this report was provided to the Administrator, Daryl Lee.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus Mixson	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 18-AS-20221214110031

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 08/11/2023

NARRATIVE
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SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus Mixson	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC9099 (FAS) - (06/04)

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