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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602479
Report Date: 07/13/2021
Date Signed: 07/13/2021 09:04:32 PM

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 SENIOR CAREFACILITY NUMBER:
374602479
ADMINISTRATOR:ANGELA BURCAFACILITY TYPE:
740
ADDRESS:193 PLUMOSA STREETTELEPHONE:
(760) 207-2645
CITY:OCEANSIDESTATE: CAZIP CODE:
92058
CAPACITY:6CENSUS: 4DATE:
07/13/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Administrator, Angela BurcaTIME COMPLETED:
05:25 PM
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Licensing Program Analyst (LPA), Kristina Ryan, conducted an unannounced case management visit. LPA was granted entry by Marin Burca and met with Administrator Angela Burca. LPA was granted entry after identifying herself and disclosing the purpose of the visit.

On June 21, 2021, The facility self-reported an incident regarding Resident 1 (R1) to Community Care Licensing.

On today's date, LPA conducted a health and safety check, and obtained resident records. No deficiencies were cited at this time.

An exit interview was conducted with Administrator, Angela Burca, to whom a copy of this report, LIC 811 Confidential Names list, and the Licensee/Appeal Rights (9058 01/16) were provided via e-mail. An electronic read receipt verifies receipt of these documents.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina RyanTELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021
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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