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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423661
Report Date: 08/28/2024
Date Signed: 08/28/2024 11:59:25 AM


Document Has Been Signed on 08/28/2024 11:59 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:AGAPE CARE HAVENFACILITY NUMBER:
336423661
ADMINISTRATOR:MARIE HUNGFACILITY TYPE:
740
ADDRESS:3750 BRISCOE STREETTELEPHONE:
(951) 682-7608
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY:6CENSUS: 5DATE:
08/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Richard Contreras, Manager TIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yolanda Delgado and Armando Perez arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility caregiver with LPA identification and business card.

Resident record review began- Five (5) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is meeting documentation requirements.

Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 115.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in the garage. All outdoor and indoor passageways are free of obstruction; two gates need to be repaired and two exit door alarms were turned off. A locked area is provided for medications and sharp objects-LPA''s observed sharp object in the drying rack. LPA verified there is a telephone working at this location.



Food Service- Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized.

LPA began review of employee records- Three (3) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification. CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and current.

(Continued on next page)
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
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 5


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 HAVEN
FACILITY NUMBER: 336423661
VISIT DATE: 08/28/2024
NARRATIVE
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(Continued on from Page 1)

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually and were last done so on 03/11/2024. The facility is conducting emergency disaster drills. The last disaster drill was conducted on 06/1/2024.

LPA allocated time to prepare this report for delivery.

Based on the information received during this visit today, there are four (4) deficiencies and civil penalties being assessed for $500 is being cited per Title 22, Division 6 of The California Code of Regulations.

This report was reviewed with Richard Contreras, LIC809D, LIC421M $500 Civil Penalty, Appeal Rights and a copy provided to the facility representative at the time of the exit interview.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/28/2024 11:59 AM - 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 HAVEN
FACILITY NUMBER: 336423661

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado and Perez's observation and interview, the licensee did not comply with the section cited above in a single pair of orange scissors was in the drying dish rack which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2024
Plan of Correction
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2
3
4
Licensee stated they will conduct staff training and post reminders to lock up sharps, never leave unattended and email LPA the training sheet, copy of the reminder by POC due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 08/28/2024 11:59 AM - 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 HAVEN
FACILITY NUMBER: 336423661

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on LPA Delgado and Perez's observation, interview and record review, the licensee did not comply with the section cited above in medications administration record for R1 and R2 is not being documented on each day being dispensed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2024
Plan of Correction
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2
3
4
Licensee stated that they will complete training with staff on section cited and implement daily checks of the medication administration records for all clients that take medications. Licensee will email training sheet and daily check list to LPA by POC due date.
Type B
Section Cited
CCR
87705(h)
Care of Persons with Dementia
(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA Delgado and Perez's observation and interview, the licensee did not comply with the section cited above in two exterior gate doors do not self-latch due to door being warped and/or missing hinge which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2024
Plan of Correction
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Licensee stated that they will repair both gates and email pictures to LPA by POC due date.
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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 08/28/2024 11:59 AM - 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 HAVEN
FACILITY NUMBER: 336423661

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA Delgado and Perez's observation and interview, the licensee did not comply with the section cited above in front door and bedroom #3 exit doors alarms were turned off poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2024
Plan of Correction
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2
3
4
Licensee stated they will conduct staff training and implement a monthly check of door alarms to ensure the facility is in complaince and email training sheet and monthly check list to LPA by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5