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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602479
Report Date: 01/17/2022
Date Signed: 01/18/2022 08:29:56 AM

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:
01/17/2022
TYPE OF VISIT:Case Management - COVID-19ANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee, Angela Burca, staff Marin Burca and Sebastian BurcaTIME COMPLETED:
10:12 AM
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Licensing Program Analyst (LPA), Kristina Ryan, and County of San Diego Nurse HAI Site Assessment Contractor, Jennifer West conducted an announced on-site visit. The team identified themselves and discussed the purpose of the visit with Licensee, Angela Burca.

The Department conducted the on-site visit to provide technical assistance and to evaluate the facility's disinfection, testing surveillance, screening protocols as well as the use of personal protective equipment. The Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Report (LIC 808) was reviewed. During today's visit, the team interviewed Ms. Burca and conducted a walk-through of the facility. A debriefing was conducted with Ms. Burca and facility staff at the conclusion of the visit.

During today's visit, no deficiencies were issued. An exit interview was conducted with Ms. Burca and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to the licensee via electronic mail. An electronic receipt confirms receipt of the documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina RyanTELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2022
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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