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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804068
Report Date: 12/09/2022
Date Signed: 12/09/2022 03:54:56 PM


Document Has Been Signed on 12/09/2022 03:54 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:
12/09/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Staff, Neil FerrerTIME COMPLETED:
04:05 PM
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
Licensing Program Analyst (LPA) Katrina Walters conducted an unannounced Post licensing inspection of this licensed senior care facility. LPA was greeted by caregiver, Neil Ferrer. The licensee was not available for today's visit. This facility is licensed for a total capacity of 6 residents, of which 6 residents can be non-ambulatory. They currently have a hospice waiver for 6 residents. LPA toured the building and grounds which were found to be clean and in good repair. During today's visit there were 5 residents living in the home who were receiving care by two staff.

The amount of fresh and nonperishable foods is within regulation. Toxins are stored behind a locked door in the laundry room and are therefore inaccessible to residents in care. There was an ample supply of PPE, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars and non-slip floors/mats. All bedrooms have lighting & appropriate furnishings. Exit alarms on exit doors were working properly.

At primary entrance LPA observed temperature log and visitor sign in sheet. LPA observed COVID postings and hand sanitizer throughout facility. Staff, were observed wearing a mouth covering and checked LPA's temperature upon entering. LPA reviewed resident records and found that residents vaccine card and updated contact information are kept in binders.

LPA requested that the facility sends current copy of Liability Insurance to Santa Rosa Community Care Licensing attention Katrina Walters.

LPA was unable to print. Report was emailed to administrator/licensee.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
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 1