<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700807
Report Date: 12/29/2021
Date Signed: 12/29/2021 10:55:55 AM

Document Has Been Signed on 12/29/2021 10:55 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: 4DATE:
12/29/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Hilary Inneh, Administrator Assistant TIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Avelina Martinez and Maja Jensen arrived at this facility unannounced on 12/29/2021 at 9:00 AM to conduct a case management visit. LPA met with Hilary Inneh and explained the purpose of the visit.

The purpose of the visit today, is in response to incident reports that were submitted to Community Care Licensing Department (CCLD) and to review Alta Regional Center (ARC) plan of correction report.

LPA requests the following information be submitted to CCLD by 01/06/2021:

  • Resident 1's (R1) Assessment Plan/IPP, LIC 602-Health Certification Form- Reassessment Plan.
  • Resident 2's (R2) Assessment Plan/IPP, LIC 602-Health Certification Form- Reassessment Plan.
  • Sanction Plan-ARC (Plan of Correction)-Verification of completed POC's
  • Fire Drill Schedules
  • Gate Repair POC
  • Incident Reports faxed to CCLD, Emails have been received, however, Incidents should also be faxed to CCLD.
  • Staffing schedule emailed to CCLD

LPA Martinez will continue to follow up on the facility issues and concerns.

As a result, of this visit, no deficiencies were cited per Title 22 Regulations. An exit review was conducted, and a copy of this report was given to the facility.

Czarrina A Camilon-Lee
Avelina Martinez
DATE: 12/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2021
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 1