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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700807
Report Date: 05/18/2021
Date Signed: 05/18/2021 11:40:23 AM

Document Has Been Signed on 05/18/2021 11:40 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:AGAPE SUPPORTED HOMESFACILITY NUMBER:
342700807
ADMINISTRATOR:OMORAGBON, OSCARFACILITY TYPE:
735
ADDRESS:3120 MOUNTAIN VIEW DRIVETELEPHONE:
(916) 993-8433
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY: 4CENSUS: 0DATE:
05/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Oscar Omoragbon, Administrator
Hilary Inneh, Administrator Assistant 		TIME COMPLETED:
12:00 PM
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Licensing Program Analysts (LPAs) Avelina Martinez and Tung Truong arrived at this facility unannounced on 05/18/2021 at 10:00 AM to conduct an annual inspection visit. LPAs met with Administrator Oscar Omoragbon and explained the purpose of the visit.

Administrator holds current certificate # 6021650735 and expires on 10/10/2022. The facility is licensed for 4 ambulatory residents. There are currently 0 residents who reside at this facility.

The LPA's toured the facility with the administrator assistant, Oscar Omoragbon, on 05/18/2021 at 10:00 AM.
LPA's inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA's also conducted the infection control domain tool.

Facility have Covid-19 posting on the walls. The facility has a main point of entry. The facility submitted a mitigation plan to CCLD. The mitigation plan was approved, and LPAs went over the mitigation plan during visit. The facility common areas are sanitary and furnished. The facility has a public telephone. The facility water temperature was 107.5 degrees. The facility has first aid kit. The facility smoke and carbon detectors are in good repair. The facility fire extinguishers were not up to date. Facility extinguishers were last inspected in Jan 2020. During the visit, facility staff had the fire extinguishers serviced at Fire Code Safety Equipment INC.

As a result of this visit, deficiencies were cited, per Title 22 Regulations, the deficiencies are cited on 809-D report. An immediate civil penalty in the amount of $500 was assessed on 5/18/2021 in regard to the facility not having fire extinguishers up to date. Exit interview was held and a 809 report, 809-D report, and appeals rights were given to Oscar Omoragbon.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2021
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 05/18/2021 11:40 AM - It Cannot Be Edited


Created By: Avelina Martinez On 05/18/2021 at 10:33 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: AGAPE SUPPORTED HOMES
FACILITY NUMBER: 342700807

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/18/2021
Section Cited

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87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
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Based on observation, interview. The licensee did not ensure fire extinguisher was up to date. Servicing tag stated last inspection was in Jan 2020.
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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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Avelina Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2021


LIC809 (FAS) - (06/04)
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