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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601419
Report Date: 11/23/2021
Date Signed: 11/29/2021 08:58:26 AM

Document Has Been Signed on 11/29/2021 08:58 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:AGAPE HOMEFACILITY NUMBER:
374601419
ADMINISTRATOR:AMADOR SAGANAFACILITY TYPE:
735
ADDRESS:267 CHURCH AVENUETELEPHONE:
(619) 271-0638
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY: 4CENSUS: 4DATE:
11/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:57 AM
MET WITH:Caregiver, Delores Sarmiento and Licensee, Amador SaganaTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an annual required licensing inspection. This annual inspection was focused on infection control due to the COVID-19 pandemic. LPA was greeted at the front entrance by Caregiver, Dolores Sarmiento and granted entry after identifying herself. Licensee, Amador Sagana arrived during the visit. LPA Hamilton explained the purpose of the visit to both Caregiver Sarmiento and Licensee Sagana. This facility serves four (4) developmentally disabled adults ages 18 through 59 years; all of whom are ambulatory.

During today's visit, LPA toured the facility, and verified compliance with infection control practices. LPA and Caregiver Sarmiento and Licensee Sagana reviewed the facility’s COVID-19 Mitigation Plan. LPA observed one central entry point; routine symptom screening initiated at entry for staff, clients and visitors; a sign in policy; signs throughout the facility to promote hand hygiene, face coverings worn by staff; hand washing stations readily available; a designated visitation area; and an adequate supply of PPE and disinfectants. LPA discussed the Provider Information Notice (PIN) regarding updated guidance on visitation.

Based on today's visit, no deficiencies were observed in the areas evaluated above. An exit interview was conducted with Licensee Sagana and a copy of this report along with the Licensee/Appeal Rights (LIC 9058) was provided via email. An electronic receipt of confirmation was requested to be sent upon receipt of the documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Elizabeth Hamilton
LICENSING EVALUATOR SIGNATURE: DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/23/2021
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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