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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004411
Report Date: 02/08/2023
Date Signed: 02/08/2023 09:49:22 AM


Document Has Been Signed on 02/08/2023 09:49 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:AGAPE HOME CAREFACILITY NUMBER:
347004411
ADMINISTRATOR:IOSIF SAMUSIFACILITY TYPE:
740
ADDRESS:7551 STONE RIDGE WAYTELEPHONE:
(916) 745-4659
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:6CENSUS: 3DATE:
02/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Daniela Samus- AdministratorTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 02/08/2023 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Administrator, Daniela Samusi, and explained the purpose of the visit. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, three (3) resident bedrooms, two (2) bathrooms, kitchen, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report sent via email.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023
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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