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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804068
Report Date: 06/07/2022
Date Signed: 06/07/2022 12:57:35 PM


Document Has Been Signed on 06/07/2022 12:57 PM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:A MOTHER'S AGAPE HOMEFACILITY NUMBER:
486804068
ADMINISTRATOR:GONZALES, VICTORIAFACILITY TYPE:
740
ADDRESS:657 CANTERBURY CIRTELEPHONE:
(707) 689-5807
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:6CENSUS: 5DATE:
06/07/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Applicant, Victoria GonzalesTIME COMPLETED:
01:07 PM
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Licensing Program Analyst (LPA), Katrina Walters arrived unannounced to conduct a pre-licensing inspection, and was greeted by staff. The applicant Victoria Gonzales arrived later. The applicant has filed a change of ownership application with the Licensing Department. The facility is currently licensed, as Agape Gardens LLC. At the time of inspection there were 2 staff, and 5 residents in care. Facility will operate with live-in staff and Licensee will ensure sufficient staffing at all times.

The facility is one story with 6 bedrooms, 3 bathrooms, office room, 2 staff rooms, and a fenced back yard. The outside grounds were free of any apparent hazards, and fire exits were clear. No accessible bodies of water. No firearms. The interior living room, dining room, kitchen and resident bedrooms were adequately furnished as required per regulation.

Fire clearance is approved for six non-ambulatory residents effective 4/29/2022. All exits were unobstructed in the home. All utilities were on and operational. All bathrooms had grab bars, and mats for the shower/bath flooring for resident use. Fire extinguishers, two (2) were serviced and tagged as required- 04/11/2022. Carbon monoxide and smoke detectors were tested and appeared to be operational. At the entrance of the facility there is a sign-in sheet with a temperature gun, and spare personal protective equipment. Facility has a 30 day supply of incontinence products and PPE. Per the applicant, they have developed a program plan, but the files, were not available for review. Applicant agreed to send LPA a copy of their dementia care plan by 6/8/22. LPA conducted Comp 3 with applicant. LPA and applicant discussed topics such as: Prohibited and Restricted conditions, Pre-Admission, Resident and Staff records, criminal background and fire clearances.

LPA will submit the pre-licensing reports to Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status. A copy of the report was given to the Applicant.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022
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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