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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004411
Report Date: 10/10/2023
Date Signed: 10/10/2023 11:33:50 AM

Document Has Been Signed on 10/10/2023 11:33 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: 2DATE:
10/10/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee: Iosif Samusi TIME COMPLETED:
11:30 AM
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On October 10, 2023, an informal meeting was held on this day via Microsoft Teams. The purpose of this meeting was to discuss the deficiencies that were issued on August 9, 2023, and to produce an acceptable plan to bring the facility into compliance. Present in the meeting was Licensing Program Manager (LPM) Troy Ordonez, Licensing Program Manager (LPM) Laura Munoz, Licensing Program Analyst (LPA) Sarena Keosavang, Licensee Iosif Samusi, facility staff, Octavian Samusi, and Rodica Samusi.

The following topics were covered during today's meeting:
  • Personal Rights violations- Unprofessional Conduct. Staff were observed yelling at the residents.
  • Personal Rights violations- Unprofessional Conduct. It was noted that staff are rearranging a resident’s room without consent and told residents that they are not allowed in the bedroom until they are done cleaning it out.
  • Plan of Corrections Completed.

Licensee agreed to do the following:
  • Facilities plan to ensure all individuals in care are treated with respect.
  • Departments expectations.
  • Departments Administrative process for failing to comply.
  • The licensee was advised at the end of the Informal Meeting that failure to correct deficiencies agreed upon during the meeting could result in a Non-Compliance Conference.


No deficiencies cited.

Exit interview conduct. Report is to be signed and submitted to LPA Keosavang via email.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2023
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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