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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004411
Report Date: 01/24/2024
Date Signed: 01/24/2024 11:06:00 AM


Document Has Been Signed on 01/24/2024 11:06 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:
01/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Licensee- Iosif SamusiTIME COMPLETED:
11:10 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
On 01/24/24, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived unannounced at the facility to conduct a Required 1- year annual inspection utilizing the care tool. LPA met with Licensee Iosif Samusi and explained the purpose of the visit.

LPA and Licensee conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to: six (6) residents room, three (3) bathrooms, kitchen, storage area, and the common areas. LPA observed the facility to have 2+ days of perishable and 7+ days of nonperishable foods.

Hot water temperature was measured at 115 degrees Fahrenheit in the bathroom sink, which is within the required range of 105 to 120 degrees. Fire extinguisher was last serviced on 12/31/23. First aid kit maintained and ready for emergency use. LPA observed toxins and knives to be locked and inaccessible to residents in care. LPA also observed centrally stored medications are kept locked and inaccessible to residents. The temperature in the facility is 75 degrees.

LPA conducted a file review of two (2) personnel and two (2) residents records. LPA observed resident records to be missing LIC625. LPA provided Licensee with a copy of the LIC625. LPA additionally provided facility with LIC311F which states required documents for personnel and resident records.

LPA completed the full care tool and deficiencies was observed. Please see LIC 809-D.

Exit interview conducted and a copy of the report and appeal rights was provided.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
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 2


Document Has Been Signed on 01/24/2024 11:06 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: AGAPE HOME CARE
FACILITY NUMBER: 347004411

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 out of 2 resident files did not have LIC625, appraisal/ needs and service plan, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2024
Plan of Correction
1
2
3
4
Licensee is to submit to LPA Ratajczak a statement of understanding as to what records are required in resident files. Licensee is to also update resident files with LIC625.
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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2